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THE REQUISITES
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THE REQUISITES IN ANESTHESIOLOGY ISBN-13: 978-0-323-02420-4
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Notice
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our knowledge, changes in practice, treatment and drug therapy may
become necessary or appropriate. Readers are advised to check the most current
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of administration, and contraindications. It is the responsibility of the practitioner, relying
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v
Contributors
vii
Preface
Obstetric and Gynecologic Anesthesia: The Requisites in throughout her pregnancy and into the postpartum
Anesthesiology provides a thorough and concise presen- period. The second section discusses care of the female
tation of the anesthetic considerations and management patient for gynecologic surgery, care of the female oncol-
of the female patient. The book includes a discussion of ogy patient, and care of the patient with chronic pelvic
the care of the pregnant patient, and it also provides infor- pain. The use of illustrations, tables, summaries, and case
mation for the care and management of the female patient studies should serve to make this a user-friendly text for
with unique pain management concerns as well as for her quick reference as well as a review of the subject. In total,
care related to gynecologic surgery. this volume should provide a concise reference for the
This book is intended for a wide audience, including care of our female patients.
the anesthesiologist needing a quick review, the resident I would like to acknowledge my many mentors, both
rotating in obstetrics and gynecology, and those prepar- past and present, without whom this book would not
ing for board examinations and recertification. Obstetric have been possible. Among them are Sanjay Datta, Gerry
and Gynecologic Anesthesia is presented in two major Ostheimer, Paul Barash, and Roberta Hines. The lessons I
sections. The first section reviews the physiology of learned from them will never be forgotten.
pregnancy and discusses care of the pregnant patient
ix
1
CHAPTER Maternal Physiology
and Pharmacology
STEPHANIE GOODMAN
PAMELA FLOOD
Physiology of the Obstetric Patient cause specific alterations that come together in the
Cardiovascular unique physiology of pregnancy.
Respiratory The adaptations that allow for the protection and
Central Nervous System nurturing of the growing fetus are generally well toler-
Head/Ears/Eyes/Nose and Throat ated by a healthy parturient. In this chapter, we will dis-
Gastrointestinal cuss the physiologic changes that occur in pregnancy in
Renal a review of systems for the parturient. We will then dis-
Hematologic cuss the pharmacologic changes of pregnancy with
Endocrine emphasis on the physiologic changes that underlie them.
Musculoskeletal These alterations should not be thought of as due to
Pharmacology in the Obstetric Patient disease, but rather as normal values during pregnancy.
Placental Transfer It is easy to imagine, however, that these physiologic
Local Anesthetics changes combined with the increased metabolic demand
Opioids of the growing fetus can worsen pre-existing maternal
General Anesthetics health problems and can even cause subclinical illness to
Inhalation Agents become manifest.
Benzodiazepines
Muscle Relaxants
Vasopressors PHYSIOLOGY OF THE OBSTETRIC
Vagolytic drugs PATIENT
Antihypertensive drugs
Antacids Cardiovascular
Antiemetics From the moment of conception, the embryo pro-
duces substances that profoundly alter the mothers
Physiologic changes occur during pregnancy that physiology. These substances prevent rejection of the
allow maternal adaptation to the demands of the growing embryos foreign proteins by the maternal immune sys-
fetus, supporting placental unit, and ultimately to facili- tem and favor transport to and implantation into the
tate labor and delivery. These modifications affect almost uterus. The effects of these embryonic-derived sub-
every organ system and influence the anesthetic and peri- stances are largely local until implantation when there is
operative management of the pregnant woman. The access to the maternal vasculature. At the time of implan-
physiologic changes of pregnancy, especially in the gas- tation (approximately 5 weeks after the last menstrual
trointestinal and cardiovascular systems, directly influ- period) changes in maternal osmoregulation begin with
ence the absorption, distribution, and elimination of increased maternal thirst and body water accumulation.
drugs. Profound changes in the hormonal milieu, the Embryonic human chorionic gonadotropin has been
mechanical effects of an enlarging uterus, the increased implicated in these early maternal physiologic changes.
metabolic demand of the fetal-placental unit, and the Osmotic thresholds for thirst and antidiuretic hormone
presence of the low-resistance placental circulation each secretion are reset to lower levels that allow for the
1
2 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
volume expansion of pregnancy. At term, total body period, the cardiac output can be increased by as much
water is increased by 6.5 to 8.5 liters. This enormous vol- as 100%. The elevation in cardiac output is a result of
ume expansion results in the hemodilution of pregnancy both an increase in heart rate and stroke volume. Heart
and elevation of maternal cardiac output (Fig. 1-1). rate begins to increase by 5 weeks gestation to a maxi-
The early volume changes of pregnancy lead to an mum of about 20% at term. Stroke volume reaches a
increased left ventricular end diastolic volume by the end maximum of a 25% increase by 20 weeks gestation. This
of the first trimester. Mild left ventricular hypertrophy is 2 L/min increase in cardiac output mainly supplies the
similar to that achieved with athletic training. Both left and uterus, kidneys, and extremities. At term, the uterine
right atrial dimensions increase as a result of the increased artery blood flow can be as high as 500 mL/min, which
preload to a maximum at 30 weeks gestation. There is no explains why an obstetric hemorrhage can so quickly
increase in central venous, right ventricular, pulmonary become life threatening.
arterial, or pulmonary capillary wedge pressures under It used to be thought that cardiac output declines
normal circumstances because of coincident dilation of around the 28th week of gestation, but it is now known
peripheral and pulmonary veins. Systemic vascular resist- that these findings were the result of positional aorto-
ance starts to decrease as early as 8 weeks of gestation. caval compression. Maternal cardiac output is depend-
Several factors, including elevated progesterone, nitric ent on position because after 24 weeks gestation, the
oxide, prostaglandins, and/or atrial natriuretic peptide, gravid uterus can completely obstruct venous return
may play a role. from the inferior vena cava in the supine position.
During pregnancy, cardiac output rises gradually, This aortocaval compression is also called the supine
beginning by 8 to 10 weeks gestation. By the end of the hypotension syndrome. At this point in gestation,
second trimester, cardiac output is elevated by 50% of women are instructed to avoid the supine position for
nonpregnant values, and in the immediate postpartum this reason. If the parturient needs to be supine for
cesarean delivery, effective prevention of aortocaval
compression includes placing the patient in a modified
lateral decubitus position by elevating the right hip
142 (with a pillow or wedge), or by tilting the entire table
or bed to the left. Cardiac output is highest when
140 measured in the left lateral decubitus position and the
PNa knee-chest position. When fetal heart rate decelerations
(mmol/l) 138 occur in labor, the parturient is placed in one of these
positions to maximize placental blood flow and thus
136 fetal oxygenation (Table 1-1).
During labor, cardiac output increases even more
134
from term values. In the absence of epidural anesthesia,
300 cardiac output can be increased from 7 to 10.5 L/m,
again because of increased heart rate and stroke vol-
296 ume. During a uterine contraction, autotransfusion
294
288
Posm
Table 1-1 Normal Hemodynamic Values in Pregnancy
(mOsm/kg) 284
Normal Values Change at Term
280
Systolic blood pressure 115 No change
Diastolic blood pressure 55 20% decrease
276
Heart rate 90 bpm 20% increase
Cardiac output 7 L/min 40% to 50%
272 increase
Central venous pressure 4 No change
MP MP LMP 4 8 12 16 Pulmonary capillary 7 No change
wedge pressure
Weeks of pregnancy Systemic vascular 1200 dyne/cm/sec 20% decrease
Figure 1-1 Change in maternal osmotic threshold. One of the resistance
first physiologic changes in pregnancy is a change in maternal Pulmonary vascular 78 dyne/cm/sec 30% decrease
osmotic set point that occurs approximately 4 weeks after the resistance
LMP at the time of implantation.
Maternal Physiology and Pharmacology 3
Nonpregnant Pregnant
Figure 1-2 Maternal skeletal changes. The maternal rib cage is widened in anterior-posterior
diameter and fore shortened.
volume that is centrally driven and under the control of that the pain threshold is elevated in pregnancy. From
progesterone. No significant change occurs in respiratory a teleologic standpoint, an elevated pain threshold would
rate. Minute ventilation is thus increased in term preg- help the mother tolerate an impending, painful delivery.
nancy, to a level almost 50% higher than in nonpregnant In the third trimester of pregnancy, sensitivity to pain is
women. The increased minute ventilation results in reduced when tested with pressure or electricity. This
a decrease in PaCO2 to approximately 30 mm Hg and change in pain sensitivity is thought to be due to increases
a small increase in PaO2 to 105 mm Hg. Arterial blood pH in spinal dynorphin (an intrinsic -opioid) and upregula-
remains essentially normal (around 7.44) because of tion of descending inhibition from noradrenergic neu-
metabolic compensation. The kidneys increase excretion rons. However, sensitivity to traditional -opioid agonists
of bicarbonate ions resulting in reduced plasma bicarbon- is not changed. Changes in maternal pain sensitivity are
ate levels of approximately 20 mEq/L (Table 1-2). thought to be due to increases in progesterone and estro-
gen. More subtle changes may occur with the hormonal
changes of menstruation. These differences brought
Central Nervous System about by pregnancy are currently being evaluated as tar-
Neurologic changes in pregnancy are more subtle gets for pain relief modalities specific to pregnancy and
than the cardiovascular and respiratory changes, but delivery. An example would be utilizing 2-adrenergic
deserve consideration nonetheless. Many people believe agonists as adjuvants for epidural analgesia.
Nonpregnant Pregnant
Inspiratory Inspiratory
capacity capacity
Total
Tidal Tidal
lung
volume volume
capacity
Figure 1-3 Static lung volumes. In pregnancy the tidal volume is increased. Functional residual
capacity is reduced largely as a result of decreased residual volume. A smaller functional residual
capacity leads to less oxygen reserve for the parturient in periods of apnea.
Maternal Physiology and Pharmacology 5
Trimester
CURRENT CONTROVERSIES: ENDOTRACHEAL
Nonpregnant First Second Third INTUBATION IN PREGNANCY
PaCO2(mm Hg) 40 30 30 30 90% of anesthesia-related maternal deaths occur
PaO2(mm Hg) 100 107 105 103 under general anesthesia.
pH 7.40 7.44 7.44 7.44 Is general anesthesia more dangerous, or do sicker
HCO3 (mEq/L) 24 21 20 20 women get general anesthesia for more emergent
situations?
ultrasound and impedance measurements, and this tently increasing fluid retention throughout pregnancy.
reduction continues into the postpartum period. Because antidiuretic hormone is not suppressed at
Systemic and neuraxial opioids may slow gastric empty- the new lower tonicity, body water is retained. Despite
ing even further. Small intestinal transit time is reduced greater antidiuretic hormone production in pregnancy,
in pregnancy. As a result, there is an increased incidence there is a 3- to 4-fold increase in its metabolism due
of constipation and bloating. to vasopressinase, an enzyme that is synthesized by
the placenta. Sodium retention increases in pregnancy
because of increased renal tubular reabsorption. Renin,
CURRENT CONTROVERSIES: SHOULD angiotensin, and aldosterone are all elevated during
PARTURIENTS BE NPO IN LABOR? pregnancy and also contribute to sodium reabsorption.
Gastric emptying is decreased in labor. Sodium excretion, however, remains normal.
Labor can last for over 24 hours, and starvation Renal blood flow and glomerular filtration rate (GFR)
ketosis can occur. increase during pregnancy. Within the first trimester,
Should apparent risk for cesarean section be renal blood flow is increased by 50% to 80%, and GFR
considered? is increased by 50%. As a result, creatinine clearance
increases by 50%. Thus, serum concentrations of creati-
nine, urea, and uric acid are decreased by almost one
Because the parturient is at increased risk for gastric third. If a pregnant patient has a normal creatinine con-
acid aspiration due to the relaxed barrier of the gastro- centration, then she has markedly reduced renal function.
esophageal junction, several strategies have been used Clearance of drugs that are excreted by the kidney and
to reduce gastric acidity (nonparticulate antacids, unchanged by the liver is therefore also increased by 50%.
histamine H2-receptor antagonists, and proton pump Dosages of these drugs and administration schedules
inhibitors) and to reduce gastric volume (metaclo- should be adjusted to compensate for these changes.
pramide). If surgery is elected, it is recommended to During pregnancy the renal glucose threshold decreases,
withhold oral intake for at least 6 hours before induction which can result in glucosuria (Table 1-4).
of anesthesia. This increased risk of aspiration again
makes regional anesthesia preferable to general anesthe-
Hematologic
sia because it allows the protective upper airway
reflexes to remain intact. When general anesthesia is The so-called anemia of pregnancy is a direct result
required, steps may be taken to reduce this increased of the retention of body water and dilution that begins in
risk. They include performing a rapid sequence induc- early pregnancy and increases progressively to approxi-
tion of anesthesia after adequate preoxygenation while mately 50% at 32 weeks gestation. There is increased
applying pressure to the cricoid cartilage in order to hematopoesis during pregnancy, but the increase in red
decrease the incidence of passive regurgitation of gas- cell mass is not as great as the increase in plasma volume;
tric acid into the oropharynx (a Sellick maneuver). An thus, there is a decrease in hematocrit. By 34 weeks ges-
endotracheal tube is the device of choice for mainte- tation, the normal hematocrit can be as low as 31%. The
nance of an unobstructed airway in parturients having increase in blood volume provides a reserve to allow
general anesthesia because other devices such as laryn- a woman to tolerate the moderate blood loss anticipated
geal mask airways do not adequately protect against at delivery. The hematopoesis that does occur during
aspiration. pregnancy often outstrips the iron supply in diet and
Liver blood flow is unchanged in pregnancy, but maternal stores. Thus anemia is partially responsive to
because of increased blood volume, portal pressure is iron treatment during pregnancy (Fig. 1-4).
increased. Pressure in vasculature that drains to the por- Dilution by plasma also causes a reduction in antibody
tal system is also elevated. As such, there is an increased titers, although no evidence exists that this decrease
incidence of perianal hemorrhoids in pregnancy. Like
other parts of the gastrointestinal system, the gall blad-
der has reduced tone. Decreased muscular activity
leads to biliary sludging. In the face of increased choles- Table 1-4 Normal Renal Function in Pregnancy
terol in pregnancy, there is an increased incidence of
cholesterol-containing gallstones. Pregnant Nonpregnant
Blood volume
80
nancy. However, women with a pre-existing tendency
Plasma volume
RBC mass to clot based on abnormalities in prothrombotic factors
70 are at even greater risk for thromboembolic phenome-
non when they become pregnant.
60 Delivery
50
Endocrine
40
Pregnancy is a diabetogenic state and is associated with
30 insulin resistance. Basal levels of insulin are increased, and
there is an increased response to a glucose challenge. As a
20 result, the changes in blood glucose are exaggerated, with
10
lower preprandial and higher postprandial glucose levels.
Also, higher levels of free fatty acids, lipids, and choles-
0 4 8 12 16 20 24 28 32 36 40 42 terol are seen. Pregnant women are more prone to the
Figure 1-4 Changes in maternal blood volume and red cell mass. production of ketones when fasting compared to non-
Both plasma volume and red cell mass increase during pregnancy. pregnant women (Fig.1-5).
There is a greater increase in plasma volume, leading to the The pituitary gland markedly increases in size during
dilutional anemia of pregnancy. (Redrawn from Scott DE: Anemia pregnancy such that it can be compressed by the optic
during pregnancy. Obstet Gynecol Ann 1: 219244, 1972.)
chiasm. In midpregnancy, growth hormone increases, but
then declines slowly until delivery. Prolactin markedly
increases in pregnancy, but then sharply decreases
causes an increased susceptibility to infection. There is after delivery, even in women who are breast-feeding.
a reduction in leukocyte chemotaxis beginning in the
second trimester that might explain the clinical improve-
ment of some autoimmune diseases in pregnancy. The
white blood cell count is normal throughout pregnancy Glucose Nonpregnant (n = 8)
Normal pregnant (n = 8)
before the onset of labor, but is often elevated during the 140
stress of labor and remains elevated postpartum.
The platelet count is normal, but platelets often 120
appear immature in a peripheral blood smear. Pregnancy
mg/DL
than 500D. Lipid solubility plays a role because highly A The placental barrier
lipid-soluble drugs cross through the placenta more easily Maternal Fetal
than water-soluble drugs. The degree of ionization
depends on whether the drug is acidic or basic, its pKa,
Unbound drug Unbound drug
and the pH of the solution. Only unionized drugs diffuse
across the placenta. The extent of plasma protein binding
also influences diffusion because only the free or
unbound drug crosses the placenta. Similar considera-
tions apply to transfer of drugs across the blood-brain bar- Protein bound Protein bound
rier. Most anesthetic drugs have the central nervous drug drug
system as an effect site, and as such, readily cross the pla- (more) (less)
centa as well.
The degree of passive diffusion is determined in part
by the surface area and membrane thickness of the B The placental barrier
placenta. Through gestation, the number of placental Maternal Fetal
villi increases and provides a growing surface area for pH 7.4 pH 7.2
drug transfer. While this occurs, the placental thickness
R-NH3 + H+ R-NH3 + H+
decreases. Thus, as pregnancy progresses, the placenta Un-Ionized Un-Ionized
gains a greater capacity for passive drug diffusion. This drug drug
results in greater drug transfer from the parturient to the
fetus in late compared to early pregnancy. However,
these considerations probably only relate to the transfer
rate. The total drug dose that reaches the fetus depends
more on the drug factors than the placental factors Ionized drug Ionized drug
R-NH3+ R-NH3+
(Fig. 1-6).
(less) (more)
Figure 1-6 Placental transfer of drugs. A, Protein binding:
Local Anesthetics equilibrium between bound and unbound free drug affects
amount available for transfer. B, pH: maternal pH affects amount
Local anesthetics are the most commonly used drugs of free or unionized drug available for transfer.
by anesthesiologists caring for the parturient. Used
almost exclusively for regional techniques, they provide
not only analgesia for labor and delivery, but also anes- well as increased epidural venous pressure and distension
thesia for instrumental deliveries and cesarean delivery. have been proposed;however, a hormonal etiology is also
Local anesthetics act as sodium channel blockers in the likely, because a reduction in required local anesthetic
neuraxis. They reduce the conduction of action poten- dose has been demonstrated as early as the first trimester,
tials and decrease the information that reaches the brain when changes in abdominal pressure are relatively
for processing from the primary nociceptors or pain insignificant.
fibers. This section focuses on the agents in current More likely, biochemical and hormonal changes influ-
obstetric anesthetic use, bupivacaine, ropivicaine, lido- ence the increased potency and spread of local anesthet-
caine, and 2-chloroprocaine and the most common ics in pregnancy. Several studies have suggested that
routes of administration, spinal and epidural. maternal nerve fibers are more sensitive to local anes-
Pregnancy changes both the pharmacodynamics and thetic effects. Bupivacaine in vitro blocks pregnant rab-
pharmacokinetics of local anesthetic drugs. The parturi- bit vagus nerves faster than those from nonpregnant
ent is more sensitive to local anesthetic blockade. Put animals, and treatment of animals with exogenous prog-
another way, a smaller spinal or epidural dose of local esterone is associated with an increased susceptibility
anesthetic given to a parturient provides the same level to blockade. Lidocaine inhibits sensory nerve action
as a greater dose would in the nonpregnant adult. This potentials in the median nerves of pregnant women to
effect is short lived after delivery. One study showed that a greater extent than in nonpregnant women. The cere-
a 30% increased dose of bupivacaine was necessary for brospinal fluid (CSF) of pregnant women contains
postpartum tubal ligation performed within 2 days after a higher progesterone concentration than in nonpreg-
delivery when compared to the dose required for nant women, which may directly augment the effect of
cesarean delivery. Several mechanisms, both mechanical local anesthetics in pregnancy. Another mechanism may
and hormonal, have been proposed to explain this phe- be associated with the pH of CSF. In pregnancy, women
nomenon. Changes in intra-abdominal pressure and infe- have increased minute ventilation, creating a mild respi-
rior vena cava compression from the gravid uterus as ratory alkalosis. The higher pH of the CSF causes more
10 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
local anesthetic to remain unionized and able to pene- pregnant sheep. However, these changes did not cause
trate membranes, and may thus increase its potency. a difference in the elimination half-life, and no difference
Bupivacaine is the most commonly used local anes- was detected in the urinary excretion of lidocaine. When
thetic in epidurals for labor in the United States, mostly compared to sheep at an earlier time in gestation, these
because it produces significant sensory and pain block- pharmacokinetic changes appear stable. Lidocaine is pri-
ade while relatively sparing motor effects. This property marily bound to 1-acid glycoprotein, and as the protein
is considered especially useful in obstetrics for main- level decreases in pregnancy, the free concentration of
taining maternal muscle tone during the descent of the lidocaine increases. Peak maternal blood levels of 6.39
fetus and the second stage of labor. Epidural bupivacaine g/mL were found at 31 minutes in women given epi-
administered for cesarean delivery has a similar serum dural lidocaine for cesarean delivery. The liver metabo-
absorption rate and elimination half-life compared to non- lizes lidocaine to monoethylglycinexylidine (MEGX) and
pregnant women. With a dose of 1.78mg/kg, the maxi- glycinexylidine (GX). MEGX can be detected in maternal
mum serum concentration of 1.39mg/L was reached in blood within 15 minutes after spinal lidocaine given for
26 minutes. The elimination half-life was 12 to 15 hours, cesarean delivery, although the mean maternal levels are
which is much longer than with an intravenous injection one tenth those after epidural doses.
because of the prolonged absorption from the epidural One ester local anesthetic, 2-chloroprocaine, has par-
space. One study demonstrated a maternal arterial peak ticular advantages as well as disadvantages when used in
concentration of 0.78 g/mL after epidural dose for obstetric anesthesia. As an ester, 2-chloroprocaine under-
cesarean delivery. None of the patients had concentra- goes rapid plasma metabolism by pseudocholinesterase
tions in the toxic range. It has been thought that the sig- to 2-chloroaminobenzoic acid (CABA). Its in vitro half-life
nificantly smaller doses of bupivacaine used for spinal is less than 15 seconds. Although pseudocholinesterase
anesthesia would not reach any significant level in the activity decreases approximately 30% with pregnancy,
maternal plasma. Detectable plasma levels of bupivacaine the in vitro half-life of 2-chloroprocaine in maternal
after spinal for cesarean delivery have been shown to be plasma is 11 seconds. With an epidural dosage in vivo,
only 5% of those found after epidural. the half-life increases to about 3 minutes because of con-
Bupivacaine is extensively bound to plasma proteins, tinuous uptake. This rapid metabolism accounts for
so as the 1-acid glycoprotein levels decrease with preg- a short duration of action, making 2-chloroprocaine a rel-
nancy, an increased percentage of the drug remains atively safe drug to use because, even if a toxic plasma
unbound in the maternal serum compared to nonpreg- level were inadvertently achieved, the ill effects would be
nant women. The liver metabolizes bupivacaine mainly short lived. However, the extremely short half-life also
to 2,6-pipecolylxylidine (PPX), and PPX can be detected makes its use for labor analgesia impractical.
in maternal plasma 5 minutes after epidural administra- The main disadvantage to using 2-chloroprocaine in
tion for cesarean delivery and continues to be detectable obstetric anesthesia for cesarean delivery is that it may
24 hours later. There does not appear to be a difference decrease the quality and duration of analgesia from epidural
in the urinary excretion of bupivacaine with pregnancy. morphine or fentanyl. Several investigators have reported
Ropivacaine, a newer local anesthetic, is still being this apparent antagonism of prior 2-chloroprocaine admin-
evaluated in pregnant humans. Potential advantages of istration which inhibits the subsequent action of epidural
ropivacaine compared to bupivicaine in obstetric use opioids. The mechanism of this interaction remains to
include decreased cardiac toxicity and decreased depth be elucidated. Epidural fentanyl produces less effica-
of motor blockade. Pregnant sheep had significantly cious sensory analgesia of shorter duration compared to
lower total clearance of intravenously administered ropi- butorphanol given after epidural 2-chloroprocaine. It is
vacaine, slightly decreased volume of distribution, and hypothesized that the etiology is -receptor based, given
no significant change in elimination half-life compared to that the analgesic action of the agonist, butorphanol,
nonpregnant sheep. The pregnant sheep also had lower is not antagonized by prior use of 2-chlorprocaine. Even a
urinary excretion of unchanged ropivacaine. Although it 2-chloroprocaine test dose of 7 mL can inhibit the duration
is quite similar in structure to bupivacaine, some phar- of action of epidural morphine. 2-Chloroprocaine does
macokinetic differences have become apparent. When bind the -opioid receptor; however, it has not been
compared for epidural use in cesarean delivery, the free proven to act as a receptor antagonist. Interestingly,
maternal plasma concentration of ropivacaine was 2-chloroprocaine has also been shown to interfere with the
almost twice as high as bupivacaine at delivery, while the efficacy and duration of action of bupivacaine. Although
elimination half-life of ropivacaine was significantly the pH of the 2-chloroprocaine solution was shown not to
shorter than bupivacaine by almost 3 hours. be the cause, a metabolite of 2-chloroprocaine has been
For lidocaine, an increased volume of distribution and implicated in the bupivicaine interaction. In isolated rat sci-
total clearance have been demonstrated after intra- atic nerves, the inactive metabolite remains bound to the
venous injection in pregnant sheep compared to non- receptor, interfering with bupivacaines subsequent effect.
Maternal Physiology and Pharmacology 11
sufentanil, and morphine. Despite this focus, crossover utes. It is 63% bound to protein in the maternal plasma
exists between locations of drug use. All opioid agonists mostly to 1-acid glycoprotein. The pharmacokinetics
have efficacy in the CNS for the treatment of labor pain. of meperidine are not changed in pregnancy. After a
Currently, the role of - and -opioid agonists is under single 50-mg intravenous dose, maternal peak plasma
investigation because of specific upregulation of these concentration of 1.5 to 3 g/mL occurred within the
systems in the maternal spinal cord. first 5 to 10 minutes, and maternal elimination half-life
Systemic opioids can be given to the parturient was 2.5 to 3 hours. Volume of distribution and clear-
by several routes: intravenously, intramuscularly, or ance were similar between pregnant and nonpregnant
subcutaneously; and their pharmacokinetic profile subjects.
depends to some extent on the route and method of Normeperidine, an active and potentially epilepto-
administration. Often they are given by bolus injection, genic metabolite of meperidine, is produced readily by
but also can be provided as patient-controlled analgesia the pregnant patient within 10 minutes of meperidine
(PCA). Continuous infusions are not recommended injection. The maternal plasma concentration of norme-
because of the intermittent intensity of the pain and peridine increases rapidly during the next 20 minutes
the risk of overdose. Typically for labor pain, systemic and continues to rise slowly throughout labor. No dif-
opioids do not provide adequate efficacy of analgesia, ferences in metabolism or urinary excretion of meperi-
but allow the parturient to better tolerate labor pain by dine or normeperidine were found in pregnancy. When
providing sedation. Numerous studies have docu- several doses of meperidine are given during labor,
mented the poor quality of pain relief after systemic normeperidine accumulation occurs with an elimina-
opioids. The choice of which drugs to use often tion half-life of over 20 hours.
depends more on institutional tradition and physician Morphine, in contrast to meperidine, does have
preference than on scientific evidence that one opioid altered pharmacokinetics in pregnancy. It can be given in
is better than another. Maternal dosing of systemic opi- 2- to 5-mg doses intravenously with an onset of 3 to 5 min-
oids is largely limited by placental transfer and by the utes or 5 to 10 mg intramuscularly with an onset of 20 to
risk of sedation and respiratory depression in the new- 40 minutes. It is metabolized to morphine-3-glucuronide
born (Table 1-5). (M3G), which is inactive. In pregnancy, morphine has
Meperidine is probably the most commonly used a faster clearance, shorter elimination half-life, and a faster
systemic opioid for labor because of long experience peak M3G level, which suggests increased morphine
and tradition. When 25 to 50 mg is given intravenously, metabolism.
the onset is within 5 minutes, and when 50 to 100 mg Nalbuphine, a mixed opioid agonist and antagonist,
is given intramuscularly, the onset is within 45 min- has a maternal elimination half-life of 2.5 hours when
given intravenously. Another mixed agonist and antago-
nist is butorphanol, which also has the benefit of a short
half-life, inactive metabolites, and provides better labor
analgesia than meperidine. Because of their antagonistic
Table 1-5 Placental Transfer of Opioids*
properties that overtake their agonist properties at
increased doses, these drugs have a ceiling effect and
Transfer Equilibrium thus theoretically carry less risk of respiratory depres-
Morphine 30% 225 min
sion and other adverse events.
Meperidine 100% NM Epidural and intrathecal opioids are useful for both
Fentanyl 25% NM labor and postoperative analgesia, especially during the
Sufentanyl 12% 45 min first stage of labor, which involves dilation of the cervix
Buprenorphine 29% 90 min and lower uterine segment. They can be used by bolus
technique or continuous infusion, in combined spinal-
* The extent of transfer of narcotic from maternal plasma to fetus. Morphine,
sufentanyl, and buprenorphine were studied in isolated human placentas. epidurals (CSE) and patient-controlled epidural analgesia
Meperidine and fentanyl were studied in rabbit placentas in vivo. Time to (PCEA). In general, the analgesia from neuraxial opioids is
equilibrium was not measured for meperidine and fentanyl. (Data from Gaylard superior to systemic opioids, and much lower doses are
DG, Carson RJ, Reynolds F: Effect of umbilical perfusate pH and controlled
maternal hypotension on placental drug transfer in the rabbit. Anesth Analg required to achieve adequate efficacy. As lower doses
71(1):4248, 1990; Kopecky EA, Simone C, Knie B, Koren G: Transfer of morphine are required, lower maternal plasma levels occur, and
across the human placenta and its interaction with naloxone. Life Sci there is less danger of fetal effects. However, neuraxial
65(22):23592371, 1999; Krishna BR, Zakowski MI, Grant GJ: Sufentanil transfer
in the human placenta during in vitro perfusion. Can J Anaesth 44(9):9961001, opioids alone are not usually sufficient analgesia for labor
1997; Nanovskaya T, Deshmukh S, Brooks M, Ahmed MS: Transplacental transfer and delivery. The addition of at least a low concentration
and metabolism of buprenorphine. J Pharmacol Exp Ther 300(1):2633, 2002; of local anesthetic is usually required to provide adequate
Vella LM, Knott C, Reynolds F: Transfer of fentanyl across the rabbit placenta.
Effect of umbilical flow and concurrent drug administration. Br J Anaesth pain relief throughout labor and delivery. Intrathecal and
58(1):4954, 1986) epidural fentanyl and sufentanil are commonly used for
Maternal Physiology and Pharmacology 13
labor analgesia. The advantage of intrathecal fentanyl intravenously administered morphine to parturients and
and sufentanil is rapid onset of pain relief in labor, little up to 1 hour, the fetal to maternal ratio of morphine is
sympathetic block, and no motor block. Morphine is less close to one. The ratio for nalbuphine is 0.78 and for
lipid soluble, has a slower onset, but a much longer dura- butorphanol is 0.9.
tion of action, which makes it useful for the treatment of When fentanyl was given intravenously to pregnant
postoperative pain. A mixture of both fentanyl and mor- women, an umbilical to maternal ratio of 0.31 was found.
phine or sufentanil and morphine can be used during This low value is thought to result from high fentanyl
cesarean delivery to take advantage of the beneficial protein binding because it is a very lipid-soluble drug.
aspects of both types of opioid. One hundred g of epidural fentanyl has a similar umbili-
Early studies of epidural morphine showed that it alone cal artery to maternal vein ratio of 0.32. An in vitro study
did not provide adequate analgesia for labor and resulted in of sufentanil showed that its placental transfer is
significant maternal blood levels of morphine. Sufentanil, increased with increased maternal dose and increased
in contrast, does provide adequate epidural analgesia for fetal acidemia but decreased with increased maternal
the first stage of labor, with a single dose lasting for 80 to protein binding. After epidural sufentanil of a mean
140 minutes. With doses between 5 and 50 g of epidural dosage of 24 g, the UV/MV ratio was 0.81.
sufentanil, maternal serum levels were undetectable.
For the treatment of postoperative pain after cesarean
delivery, 2 to 5 mg of epidural morphine provides analge- General Anesthetics
sia for a mean duration of 23 hours. The optimal dose is Intravenous induction agents are used most fre-
thought to be 3 mg because side effects increase with quently to induce general anesthesia for patients who
increased dose, and the analgesic effect is maximal at require emergency cesarean delivery or have con-
3 mg. Epidural morphine has been shown to provide bet- traindications to regional anesthesia. Smaller doses of
ter analgesia than morphine given intramuscularly or by these drugs, however, are useful in cases in which
PCA. Intrathecal morphine has similar duration and side some pain relief and sedation are necessary, such as
effects compared to epidural morphine, but a smaller during removal of a retained placenta. In obstetric anes-
dose is required. With an intrathecal dose of 0.6-mg mor- thesia, thiopental and ketamine are used much more
phine, maternal plasma levels peaked at 3 hours at a con- than propofol and etomidate. Although the choice of
centration of 0.61 ng/mL. Doses as low as 0.1 to 0.25 mg agent does depend on the specifics of each clinical situ-
of intrathecal morphine have been used effectively for ation, maintaining maternal hemodynamic stability and
pain after cesarean delivery and provide analgesia for uterine blood flow and minimizing neonatal sedation
18 to 28 hours. are important considerations.
In general, because opioids alone do not provide In the first trimester of pregnancy, a reduced dose of
complete analgesia for labor and delivery, they are most thiopental (by as much as 18%) is required to anesthetize
often used in combination with local anesthetics. Very a pregnant woman when compared to a nonpregnant
dilute local anesthetic solutions that would alone be woman. After an average induction dose of 261 mg, the
ineffective can be used because the local anesthetic and mean venous thiopental concentration was 17 g/mL in
the opioid have a synergistic interaction. This strategy pregnant women. Although there is no change with
helps reduce side effects from each drug. In obstetric pregnancy in the percentage of thiopental bound to
anesthesia, this is particularly useful because reduced plasma proteins, thiopental does have a relatively larger
local anesthetic doses cause less motor blockade. As the volume of distribution and longer elimination half-life in
epidural dose of fentanyl increases, the minimum local pregnant patients.
analgesic concentration (MLAC) of epidural bupivacaine The pharmacokinetics of ketamine in pregnancy have
for labor significantly decreases. This effect is true for not been studied as extensively as barbiturates. The use-
epidural 2-chloroprocaine as well. Local anesthetics, ful properties of ketamine in general, its sympath-
combined with opioids, can be useful for anesthesia for omimetic effects on the cardiovascular and pulmonary
cesarean deliveries, and continuous infusions of PCEA systems, make it similarly useful in obstetric anesthesia,
treatment provide effective postoperative pain relief and especially for hypovolemic or asthmatic patients.
enhanced mobility after surgery. A unique side effect of ketamine, increased uterine con-
All opioids are readily transferred across the placenta traction frequency and intensity, has important conse-
because they have molecular weights less than 500. quences for the parturient. Ketamine-induced uterine
Meperidine can be detected in the fetal plasma 2 minutes hypertonicity and uterine artery vasoconstriction could
after maternal drug administration. The ratio between worsen a placental abruption or decrease the uteropla-
umbilical to maternal venous meperidine concentrations cental blood flow to the fetus. This increased uterine
increases with time from 1 to 4 hours, and ratios of one tone is dose related and not generally seen with doses
or higher can be found after 2 hours. After 5 minutes of less than 1 mg/kg. Ketamine causes hallucinations in the
14 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
parturient, as it does in nonpregnant women. When ket- maternal progesterone concentrations because the
amine is used to induce anesthesia for emergency change occurs as early as the first trimester of pregnancy.
cesarean delivery, consideration should be given to the The minimum alveolar concentration (MAC) in animals
coadministration of an anesthetic or sedative that pro- was demonstrated to be lower with pregnancy, by as
vides amnesia, such as a benzodiazepine or barbiturate. much as 40% for isoflurane. More recently, similar reduc-
Etomidate is not routinely used for parturients unless tions have been shown in humans. MAC for isoflurane in
there is particular concern for maintaining hemody- humans is reduced by 28% as early as 8 to 12 weeks gesta-
namic stability because it has the benefit of causing mini- tion and returns to normal by 12 to 24 hours postpartum.
mal cardiovascular depression. Its pharmacokinetics in Other inhalation agents, such as halothane and enflurane,
pregnancy have not been well studied. After 0.3 mg/kg have equal pregnancy-induced decreased MAC.
of etomidate for induction of general anesthesia for The volatile anesthetics all produce uterine relax-
cesarean delivery, the mean maternal plasma etomidate ation. In experiments with human uterine muscle strips
concentration was 1242 ng/ml, which decreased quickly there is an equal depression of contractility caused by
and was undetectable at 2 hours after injection. In enflurane, halothane, and isoflurane, and this decrease
one study, APGAR scores were not different when the is dose dependent. Although a statistically significant
mother was induced for cesarean delivery with eto- reduction in contractility exists even at 0.5 MAC, these
midate compared to methohexital. Cortisol levels ini- doses of isoflurane and halothane used with nitrous
tially dropped in the newborns born after etomidate oxide in oxygen for maintenance of general anesthesia
induction, but there was no difference after 6 hours. for cesarean delivery have not been associated with
Etomidate is initially found in the colostrum but is unde- increased maternal blood loss. Similarly, the newer
tectable at 4 hours after injection. inhalation agents, desflurane and sevoflurane, do not
Propofol has similar pharmacokinetic properties in increase postpartum blood loss.
pregnant women compared to nonpregnant women. No If used for labor analgesia, isoflurane administered in
difference exists in volume of distribution or elimination subanesthetic doses ranging from 0.2% to 0.7% during
half-life, but pregnant women do have a more rapid clear- the second stage of labor can provide satisfactory analge-
ance of propofol. It is not known whether this repre- sia in approximately 80% of mothers. This was not asso-
sents increased hepatic metabolism or simply removal of ciated with significant maternal amnesia or blood loss. In
the drug through the delivery of the placenta and loss of contrast, desflurane, which has a very low bloodgas
blood. Propofol does not seem to have significant advan- partition coefficient of 0.41 and is similar to nitrous
tages over other induction agents for the parturient. oxide in this respect, was associated with a significant
rate of maternal amnesia for the delivery of the baby.
Inhalation Agents
A mixture of 50% nitrous oxide and 50% oxygen used Benzodiazepines
to be intermittently self-administered by a laboring As sedatives and anticonvulsants, the benzodiazepines
woman with each contraction for labor analgesia. Now, have limited use in obstetric anesthesia. In large doses,
with the effective pain relief provided by spinal and they can be used for a hemodynamically stable induction
epidural analgesia, this less efficacious treatment is no of general anesthesia but cause significant neonatal side
longer routinely available in the United States. If general effects, often described as floppy infant syndrome.
anesthesia is used for cesarean delivery, then the inhala- While diazepam can be used to prevent eclamptic
tion agents are frequently used for maintenance of anes- seizures, magnesium is more commonly used for this pur-
thesia but not for induction because the parturient pose in the United States. In addition, the amnesia caused
requires a rapid sequence induction and rapid airway by benzodiazepines, which is beneficial in many nonob-
control to prevent regurgitation and aspiration. In emer- stetric situations, is not desirable in labor and delivery
gency situations in which profound uterine relaxation is because most women want to remember the experience
needed, such as for delivery of a second twin or removal of childbirth. For some women, however, a small dose of
of a retained placenta, these agents are particularly use- a short-acting benzodiazepine such as midazolam can be
ful. Most commonly, nitrous oxide is used in combina- useful to decrease severe anxiety when receiving a neu-
tion with isoflurane, but the newer agents, desflurane raxial anesthetic for cesarean delivery and should not be
and sevoflurane, can also be used. The combination of sufficient to impair memory of the birth.
gasses decreases maternal awareness and increases the After a 5-mg intravenous bolus dose of midazolam, the
inspired concentration of oxygen. mean plasma midazolam concentration is lower in preg-
It is well known that pregnancy is associated with nant than in nonpregnant women due to the larger
lower general anesthetic requirements. While the mecha- apparent volume of distribution. The elimination half-life
nism remains uncertain, it has been attributed to higher of midazolam, approximately 50 minutes, is not affected
Maternal Physiology and Pharmacology 15
by pregnancy. When used for induction, midazolam has a Pregnant patients also have a more rapid clearance of
slower induction time compared to thiopental, which vecuronium than nonpregnant patients. In pregnant
could put the parturient at risk for aspiration. Unlike patients, rocuronium has a very similar onset of action,
midazolam, the elimination half-life of diazepam is greatly 79 seconds, and duration of action, 33 minutes after
prolonged, 65 hours compared to 29 hours in nonpreg- 0.6 mg/kg, compared to vecuronium. The duration
nant women. of rocuronium is also prolonged in postpartum
patients compared to nonpregnant patients. Recovery
from mivacurium is slightly prolonged (from 16 to
Muscle Relaxants 19 minutes) in pregnancy, perhaps because of reduced
When general anesthesia is used for cesarean deliv- plasma cholinesterase available for its metabolism. In
ery or other obstetric surgical procedures, muscle contrast to vecuronium, rocuronium, and mivicurium,
relaxants are often necessary to facilitate intubation of atracurium does not have a prolonged duration of action
the trachea and to provide abdominal muscle relax- in peripartum patients. Magnesium, used in the treat-
ation to improve the surgical conditions. Obstetric ment of pre-eclampsia, will prolong the duration of all
patients require rapid sequence induction of general nondepolorizing neuromuscular blocking drugs, but the
anesthesia, and succinylcholine is the drug of choice duration of action of succinylcholine is not affected.
because of its rapid onset and rapid degradation by
plasma cholinesterases. The nondepolarizing muscle
relaxants are used most frequently for maintenance of DRUG INTERACTION: MAGNESIUM AND MUSCLE
muscle relaxation and for induction if the use of suc- RELAXANTS
cinylcholine is contraindicated, such as in pseudo- Magnesium enhances the neuromuscular blockade
cholinesterase deficiency. Long-acting nondepolarizers produced by nondepolarizing neuromuscular block-
such as pancuronium, curare, and metocurine are ing drugs.
rarely used in obstetrics because the intermediate- Magnesium is used frequently in obstetrics for both
acting drugs like vecuronium, atracurium, and rocuro- the treatment of preterm labor and seizure prophy-
nium are available and have a more appropriate duration laxis in pre-eclampsia.
of action for the average cesarean delivery. Neuromuscular blocking drugs must be dosed
carefully in these patients.
Succinylcholine is rapidly metabolized by plasma
cholinesterase, and its limited time of effect is what
makes it so useful. In patients with decreased enzyme
activity, succinylcholine has a longer duration of action.
It is well established that plasma cholinesterase activity Vasopressors
is 30% less with pregnancy, but the recovery from suc- It is very common after placement of a spinal anes-
cinylcholine is not significantly prolonged in pregnant thetic for cesarean delivery or even after the spinal dose
women. This apparent contradiction is best explained of a CSE analgesic to require a vasopressor to support
by an increased volume of distribution of succinyl- the blood pressure. In this case, rapid resolution of
choline in pregnancy, which causes a decreased appar- hypotension is important because neonatal acidemia
ent dose. However, in the postpartum period, when will otherwise result. Vascular tone is tonically modu-
enzyme activity remains decreased, but the volume of lated by activation of both 1- and 2-adrenergic recep-
distribution begins to normalize, the recovery from suc- tors in blood vessels. Because maternal sensitivity
cinylcholine is prolonged by 3 minutes compared to to catecholamines is reduced, more agonist drug is
control patients. The common side effects of succinyl- required to activate both receptor subtypes in preg-
choline, fasciculations and myalgias, are significantly nancy. There is a larger reduction in 1-adrenergic sensi-
decreased in pregnant compared to nonpregnant tivity compared to 2, which might contribute to the
patients, and pretreatment with d-tubocurarine does not vasodilatory state of pregnancy. Ephedrine has tradition-
further decrease the incidence of these side effects in ally been the drug of choice for the treatment of
pregnancy. hypotension in pregnancy due to its and receptor-
Several muscle relaxants have prolonged action in stimulating properties and because it does not decrease
pregnancy. Vecuronium, when administered in a dose uterine blood flow in moderate doses. Other drugs have
according to body weight, has a significantly faster onset previously been considered contraindicated in obstetric
in pregnant women, 80 seconds compared to 144 sec- anesthesia because of a fear of placental vasoconstric-
onds in nonpregnant females, and a longer duration of tion leading to fetal asphyxia. More recent work has
action, 46 minutes compared to 28 minutes. As such, to shown that treating the hypotension effectively is much
maintain stable muscle relaxation, pregnant patients more important than which agent is chosen. Increasing
require smaller doses of vecuronium than controls. the pressure head to the placenta is more important
16 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
than any vascular constriction that might be caused by resort because of the risk of rapid fluctuations in mater-
an -adrenergic agonist. In this regard, phenylephrine nal pressure and the increased risk of cyanide toxicity to
had always been thought to decrease uterine blood the fetus. -Blockers are becoming more commonly used
flow, but when used to treat hypotension after spinal in pregnancy. The pharmacokinetics of propranolol are
anesthesia for cesarean delivery, it has been shown similar during pregnancy and the postnatal period.
to result in less maternal hypotension and neonatal Labetolol has theoretical advantages over pure -recep-
acidemia than ephedrine. Because phenylephrine has tor antagonists due to its ability to antagonize recep-
primarily -receptor agonist effects, it can be used to tors as well. When administered orally, it has an
avoid or decrease the tachycardia associated with exces- elimination half-life ranging from 4 to 7 hours. The cal-
sive ephedrine use. cium channel antagonists have not been well studied in
pregnancy but have specific utility for treatment of both
maternal and fetal arrhythmias in addition to maternal
DRUG INTERACTION: ERGOT ALKALOIDS AND hypertension.
VASOPRESSORS
Ergot alkaloids effect uterine contractions and are Antacids
useful in the treatment of postpartum hemorrhage.
Their mechanism of action is probably via -adrenergic Most studies involving antacids traditionally assess effi-
receptors. cacy by using a gastric volume of greater than 25 mL and
The combination of an ergot alkaloid and a vasopres- a pH of less than 2.5 as indicators of increased risk of aspi-
sor may lead to extreme hypertension. ration. More recently, though, these cutoffs have been
challenged because no outcome data has suggested that
obtaining these values reduces the risk of acid aspiration
syndrome. Still, most drug therapy is used to increase gas-
tric pH because altering gastric volume is much more diffi-
Vagolytic Drugs cult to accomplish. Both H2 antagonists and proton-pump
After a single 0.01-mg/kg dose of intravenous atropine inhibitors, particularly in combination with nonparticu-
given during cesarean delivery, the distribution half-life is late antacids, are effective at reducing gastric pH.
1 minute while the elimination half life is 3 hours. Because the aspiration of particulate matter can be as
Intramuscular glycopyrrolate is rapidly absorbed prior to damaging to the lung as acid aspiration, nonparticulate
cesarean delivery and has an elimination half-life of antacids are recommended. One effective oral antacid is
33 minutes, which is shorter than in nonpregnant the administration of 30 mL of 0.3-molar sodium citrate
females. Approximately half of the drug is excreted in given no more than 60 minutes in advance of cesarean
the urine within 3 hours. Intravenous glycopyrrolate delivery. When more time is available between drug
(0.005 mg/kg) and intravenous atropine (0.01 mg/kg) administration and surgery, such as for an elective
administered to laboring parturients have equal effects cesarean delivery, 400 mg of cimetidine, the prototypic
on maternal heart rate and blood pressure. Scopolamine, histamine H2-receptor antagonist, can be given orally 90
used in the past for twilight sleep in labor, has a simi- to 150 minutes in advance. Ranitidine has several advan-
larly rapid intramuscular absorption rate with an elimina- tages over cimetidine. It does not have as many interac-
tion half-life during pregnancy of 1 hour. tions with other drugs; it raises gastric pH within an hour
of intravenous administration, and it lasts longer. Several
studies have shown its improved efficacy when given in
Antihypertensive Drugs conjunction with sodium citrate. Omeprazole, a proton
Several different classes of drugs can be used for the pump inhibitor, is also useful in reducing gastric pH in
treatment of hypertension in pregnancy. Angiotensin- pregnant patients. It has a long duration of action and
converting enzyme (ACE) inhibitors are the only class binds directly to the pump. Its plasma half-life, on the
contraindicated due to its association with fetal renal fail- other hand, is only 0.5 to 1.5 hours. This results in rela-
ure and intrauterine death. These drugs would not be tively low maternal plasma concentrations. Omeprazole
very effective in pregnancy anyway because the normal has also been shown to be efficacious when used with
pregnant woman is resistant to the action of angiotensin- metaclopramide and sodium citrate.
II. For acute treatment of hypertension, especially in pre-
eclampsia, hydralazine is used most frequently because
of its long safety history and rapid pharmacokinetics. Antiemetics
After intravenous bolus, it has an onset of action of 20 to There are many causes of nausea and vomiting in
30 minutes. Sodium nitroprusside lowers blood pressure the parturient. Some of these include pregnancy itself,
much more quickly, but this drug is used only as a last labor, opioids administered systemically, intrathecally, or
Maternal Physiology and Pharmacology 17
epidurally, as well as spinally mediated hypotension dur- easily accommodated in the healthy parturient, and some
ing cesarean delivery. If treatment is required, options are beneficial, for instance in preparation for blood loss
include ondansetron, dolasetron, droperidol, and meto- at the time of birth. It is easy to imagine, however,
clopramide. Depending on the situation, each has advan- how these changes could overcome physiologic compen-
tages and disadvantages. Most studies involving the use sation in a patient with subclinical disease of any organ
of these drugs in pregnancy assess efficacy and not phar- system. It is thus the role of the anesthesiologist, along
macology. Ondansetron and dolasetron, the newest and with our obstetric colleagues, to ensure that the new nor-
most expensive of the four, are less studied during mal values of pregnancy are maintained and well
pregnancy. tolerated by the parturient, to ensure successful delivery
Metoclopramide has been shown to decrease the vol- of the newborn.
ume of stomach contents in early pregnancy, in estab-
lished labor, and before elective cesarean delivery. There
SUGGESTED READING
is also evidence that metoclopramide can be used pro-
phylactically in women having spinal or epidural anes- Chadwick HS, Posner K, Caplan RA, et al: A comparison of
thesia for elective cesarean delivery to decrease the obstetric and nonobstetric anesthesia malpractice claims.
incidence of nausea and vomiting throughout the periop- Anesthesiology 74(2):242249, 1991.
erative period. In sheep, the maternal elimination half- Gintzler AR, Liu NJ: The maternal spinal cord: Biochemical and
life of metoclopramide is 71 minutes, which is only physiological correlates of steroid-activated antinociceptive
slightly prolonged compared to the nonpregnant value processes. Prog Brain Res 133:8397, 2001.
of 67 minutes. Total body clearance and volume of Gordon MC: Maternal physiology in pregnancy. In Gabbe SG,
distribution are lower in the pregnant ewe compared to Niebyl JR, Simpson JL (eds): Obstetrics: Normal and Problem
the nonpregnant ewe, but dose reduction is not neces- Pregnancies. 4th edition, Philadelphia, Churchill Livingstone,
sary. Ondansetron and droperidol have each been shown 2002, pp 6392.
to be effective prophylaxis against nausea and vomiting Kanto J: Obstetric analgesia: Clinical pharmacokinetic consid-
after elective cesarean delivery compared to placebo, erations. Clin Pharmacokinet 11(4):283298, 1986.
but there was no statistical difference in prophylaxis Krauer B, Krauer F, Hytten FE: Drug disposition and pharmaco-
between treatments. Ondansetron has been shown to be kinetics in the maternal-placental-fetal unit. Pharmacol Ther
more effective at preventing nausea than metaclo- 10(2):301328, 1980.
pramide and placebo in a randomized trial during Maternal adaptation to pregnancy. In Cunningham FG, Gant NF,
cesarean delivery. Because the FDA has placed a black Leveno KJ, et al (eds): Williams Obstetrics, 21st edition. New
box warning on droperidol packaging indicating its York, McGraw-Hill, 2001, pp 167200.
possible implication in cardiac arrhythmias, metaclo- Mucklow JC: The fate of drugs in pregnancy. Clin Obstet
pramide, dolasatron, and ondansetron remain the best Gynaecol 13(2):161175, 1986.
alternatives for prophylaxis and treatment of nausea and Pacifici GM, Nottoli R: Placental transfer of drugs administered
vomiting after cesarean delivery. to the mother. Clin Pharmacokinet 28(3):235269, 1995.
Pregnancy represents a new normal state with Pilkington S, Carli F, Dakin MJ, et al: Increase in Mallampati
markedly increased body fluid volume, increased cardiac score during pregnancy. Br J Anaesth 74(6):638642, 1995.
output, and lung and kidney function. These changes are
2
CHAPTER Anesthesia for
Nonobstetric Surgery
During Pregnancy
JULIO E. MARENCO
ALAN C. SANTOS
Introduction
Maternal Safety MATERNAL SAFETY
Cardiovascular Changes
Respiratory System Pregnancy is associated with changes in maternal
Gastrointestinal Changes physiology that affect anesthetic management. Whereas
Changes in Anesthetic Requirement these changes are well described at the end of preg-
Fetal Outcome nancy, there are few systematic studies on how altered
Teratogenicity physiology due to pregnancy can affect anesthetic man-
Reproductive Outcome Studies agement in the first or second trimester. Generally speak-
Laparoscopy ing, physiologic alterations in the first half of pregnancy
Preserving Uterine Blood Flow are under hormonal control; whereas in the latter half of
Clinical Recommendations pregnancy, the mechanical effects of a growing uterus
supervene.
18
Anesthesia for Nonobstetric Surgery During Pregnancy 19
diazepam and bupivacaine, may be increased during due to the aforementioned alveolar hyperventilation.
pregnancy. Alveolar hyperventilation may also result in faster induc-
Cardiac output increases progressively during preg- tion with an inhalational agent due to a greater rate of
nancy, in part, related to the aforementioned increase in rise in the alveolar partial pressure of the gas.
total blood volume. However, there is also a redistribu- Vascular engorgement of the oropharynx and respira-
tion of cardiac output resulting in an increase in blood tory tract may render laryngoscopy and tracheal intuba-
flow to the uterus and mammary glands. Concomitantly, tion difficult due to edema and bleeding, particularly
systemic vascular resistance is decreased due to the if repeated attempts are required. Indeed, studies in
smooth muscle-relaxing effects of progesterone and pregnant women have shown that the use of general
prostacyclin, which are elevated during pregnancy, and anesthesia is associated with a case fatality rate that is
also due to the growth of the placenta, which acts as a 16.7 times greater, almost exclusively due to difficulties
low-resistance vascular bed. The net result is that arterial with airway management, than for regional anesthesia.
blood pressure tends to be normal or slightly decreased There are other reasons why a pregnant woman may be
in pregnant as compared to nonpregnant women. more difficult to intubate. During pregnancy, the mam-
A decrease in cardiac output may occur in the supine mary glands enlarge, making it technically difficult
position during the second half of pregnancy due to to perform laryngoscopy. Also, the anteriorposterior
compression of the aorta and inferior vena cava by a diameter of the thorax increases, which may make it dif-
growing uterus. Compression of the vena cava may result ficult to place the woman in an optimum sniff position.
in reduced venous return to the heart and a decrease in Consequently, the likelihood of a pregnant woman being
cardiac output whereas aortic compression results in unable to be intubated is almost 10 times more common
reduced blood flow (and pressure) below the level of than for surgical patients.
obstruction. In its most severe form, compression of the
great vessels in the supine position results in the Supine
Hypotension Syndrome, which affects 10% to 15% of Gastrointestinal Changes
mothers and is manifested by lightheadedness, hypoten- Its well accepted that the pregnant woman at term,
sion, tachycardia, diaphoresis, and even syncope. Thus, particularly if in labor or having received systemically
it is critical to ensure that the uterus be adequately dis- administered opioids, is at risk for aspiration pneumoni-
placed during anesthesia and surgery from the fifth tis. Unfortunately, it is less clear at what point in gesta-
month of gestation onward. tion individual women become at risk for aspiration.
During pregnancy, increasing progesterone levels inhibit
gastric emptying and intestinal motility. The competency
Respiratory System of the gastroesophageal sphincter is compromised by the
Pregnancy increases the risk of hypoxemia during relaxant effects of progesterone and due to the mechani-
periods of apnea and hypoventilation, particularly after cal effects of the uterus pushing the stomach upwards.
the fifth month of gestation. This is mostly related to two Indeed, a delay in gastric emptying has been observed as
factors: a 15% to 20% decrease in functional residual early as 8 to 11 weeks of gestation and becomes signifi-
capacity and an almost equal increase in the rate of oxy- cant at 12 to 14 weeks of pregnancy. Women who com-
gen consumption. Therefore, supplemental oxygen plain of frequent heartburn may be at greatest risk of
should be administered routinely to pregnant women aspiration. Finally, the pH of gastric secretions is lower as
during the immediate perioperative period. Indeed, the early as the first trimester in pregnancy due to placental
rate of decline in maternal PaO2 is greater in pregnant secretion of gastrin.
(139 mm Hg/min) as compared to nonpregnant women Prevention of aspiration is of the utmost importance
(58 mm Hg/min) during periods of apnea. Thus it is (Box 2-1). Preoperative administration of histamine H2-
imperative that denitrogenation (preoxygenation) pre- receptor antagonists may be used to decrease the volume
cede induction of general anesthesia. This can be accom- and acidity of gastric secretions. However, these require
plished by the mother breathing 100% oxygen for time to be effective and will not increase the pH of gastric
5 minutes or by taking four vital capacity breaths. secretions that are present in the stomach prior to drug
Supplemental oxygen should also be administered rou- administration. In this regard, nonparticulate antacids,
tinely to women having regional anesthesia. such as sodium citrate, are very effective in neutralizing
Minute ventilation increases during pregnancy, and, gastric secretions and should be routinely administered
as a result, PaCO2 lower (32 to 34 mm Hg) mostly due to prior to induction of anesthesia. Particulate antacids,
an increase in tidal volume. It is ironic that pregnant on the other hand, should be avoided because aspiration
women are more vulnerable to developing hypoxemia, of colloidal suspensions may result in a severe form of
considering that the resting PaO2 is actually higher (PaO2 aspiration pneumonitis having long-term consequences.
104 to 106 mm Hg) than that of nonpregnant women Advance administration of metoclopramide promotes
20 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
wait until after the first trimester (where the mothers condition, the site of surgery, and the poten-
theoretic risk of teratogenicity is lower), as long as tial jeopardy to the fetus. To date, there is no known
the mothers condition allows. The optimum period study suggesting that continuous fetal monitoring
for surgery during pregnancy may be from the 20th results in better fetal outcome if the mother has
to 24th week of gestation when there is the lowest anesthesia and surgery while pregnant. However,
risk of teratogenicity and premature labor. if the fetus is viable, it would seem prudent that
2. Pain and anxiety should be treated with the an obstetrician be available to manage obstetric
appropriate medication. Considering the available complications related to the surgical procedure.
evidence and the many alternatives at hand, it 10. Surgical pain may mask premature labor, and for that
would seem prudent to avoid the use of diazepam reason, it may be necessary to monitor uterine activity
in the first trimester. in the immediate postoperative period.
3. Prophylaxis for aspiration (see Box 2-1) may include 11. Maternal pain relief should be a priority. The patient
preoperative administration of an H2-receptor antag- should receive postoperative supplemental oxygen for
onist and metoclopramide. Sodium citrate should as long as required. Uterine displacement should be
be routinely administered to neutralize existing gas- routinely practiced intraoperatively and immediately
tric secretions. postoperatively.
4. From the fifth month of pregnancy on, uterine
displacement should be routine.
5. Supplemental oxygen should be administered REFERENCES
perioperatively, particularly when maternal illness, 1. Mazze RI, Kallen B: Reproductive outcome after anesthesia
anesthesia, or postoperative pain medications may and operation during pregnancy: A registry study of 5405
result in hypoventilation. cases. Am J Obstet Gynecol 161:11781185, 1989.
6. No one anesthetic technique has emerged as 2. Duncan PG, Pope WDB, Cohen MM, Greer N: Fetal risk of
preferable. Rather, the choice of anesthetic should be anesthesia and surgery during pregnancy. Anesthesiology
based on maternal condition, the proposed surgery, 64:790794, 1986.
and anticipated duration. Procedures involving the
pelvic organs or for obstetric indications carry an SUGGESTED READING
additional risk of adverse reproductive outcome.
7. If general anesthesia is chosen, it is critical to Archer GW, Marx GF: Arterial oxygenation during apnoea in
prevent arterial oxygen desaturation during the parturient women. Br J Anaesth 46:358360, 1974.
period if induction by meticulous preoxygenation. Baden JM: Mutagenicity, carcinogenicity, and teratogenicity of
Currently, there is no evidence preventing the use nitrous oxide. In Eger EI II, (ed): Nitrous Oxide/N2O. New
of N2O as long as the inhaled concentration is less York, Elsevier, Inc., 1985.
than 50% and exposure is not prolonged (see Hawkins JL, Koonin LM, Palmer SK, Gibbs CP: Anesthesia-
Box 2-4). Regional anesthesia, although theoreti- related deaths during obstetric delivery in the United States,
cally decreasing the risk of aspiration, has its own 19791990. Anesthesiology 86:277284, 1997.
complications, such as hypotension. Heinonen OP, Slone D, Shapiro S: Birth Defects and Drugs
8. Maternal surveillance should at least include all of in Pregnancy. Littleton, MA, Publishing Sciences Group,
the basic monitors recommended by the American 1977.
Society of Anesthesiology. Depending on the sever- Mazze RI, Kallen B: Appendectomy during pregnancy.
ity of maternal disease and the extent of the pro- A Swedish registry study of 778 cases. Obstet Gynecol 77:
posed surgery, additional invasive monitors may be 835840, 1991.
required. Reedy MB, Kallen B, Kuehl TJ: Laparoscopy during pregnancy:
9. Fetal monitoring remains controversial. Most would A study of five fetal outcome parameters with the use of the
agree that it is sufficient to confirm a fetal heart Swedish Health Registry. Am J Obstet Gynecol 177:673679,
rate prior to and at the conclusion of the procedure 1997.
if the fetus is previable. If the fetus is viable, decisions Rosen MA. Management of anesthesia for the pregnant surgical
regarding continuous fetal monitoring during anes- patient. Anesthesiology 91:11591163, 1999.
thesia and surgery should be made on an individual Samsoon GLT, Young JRB: Difficult intubation. Anaesthesia
case-by-case basis, taking into consideration the 42:487490, 1987.
3
CHAPTER Anesthetic
Considerations for
Fetal Surgery
FERNE R. BRAVEMAN
25
26 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
Table 3-3 Fetal Defects That May Be Indications for Table 3-4 Drugs to Be Immediately Available for
Repair via Fetoscopy Intraoperative Fetal Administration
PAMELA FLOOD
29
30 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
began to be recognized and placental transfer was bet- of the afferent nociceptive fibers and on the receptive dor-
ter understood. Regional analgesia for childbirth also sal horn neurons as well. The descending noradrenergic
developed during the early years of the twentieth cen- pathway is a tonically active modulatory system that can be
tury, but developed slowly because of the difficulty of thought of as a volume control for pain transmission. This
the techniques and the lack of wide availability of local system is upregulated in pregnancy and is also involved
anesthetic drugs. in the analgesia associated with stress and trauma. The
norepinephrine released from these neurons activates 2-
adrenergic receptors just as do the synthetic analogs cloni-
PAIN TRANSMISSION IN PARTURITION dine and dexmedetomidine to provide analgesia.
The serotonergic neurons that provide native analgesic
Pain during the first stage of labor occurs mostly dur- mechanisms are located in the median raphe nuclei in the
ing contractions and is due to contraction of the uterus brain. They also project caudally in the spinal cord, where
and distention of the cervix and vagina. Visceral afferent they synapse on the dorsal horn neurons. These seroton-
pain fibers from the uterus, cervix, and upper vagina ergic inputs can be either facilitatory or inhibitory, but
form the cervical plexus and enter the spinal cord at the overall they provide analgesia. There is also evidence for
T10L1 levels. The visceral afferent fibers also enter the tonic activity of this system.
sympathetic chain at L2 and L3 levels.
In the second stage of labor, expulsion of the fetus
activates somatic afferent pain fibers from the mid and NONPHARMACOLOGIC TECHNIQUES
lower vagina, vulva, and perineum. These signals are FOR LABOR PAIN
conveyed via the S2S4 spinal nerve roots that form the
pudendal nerve. The pudendal nerve projects bilaterally During the early years of analgesia and anesthesia for
through the inferior sciatic foramen, where it is accessi- labor, there were significant maternal and fetal complica-
ble for blockade by local anesthetics. Neuraxial represen- tions. Beside maternal hypotension, fetal asphyxia, and
tation of labor pain is not continuous, and the interceding maternal gastric aspiration, the most common com-
segments represent and mediate the sensory and motor plaint about early techniques for labor analgesia was the
innervation of the lower extremities. lack of maternal participation in the birth experience.
Ether and chloroform provided anesthesia in addition to
analgesia. Twilight sleep including the anticholinergic
Neurophysiology of Pain Transmission drug scopolamine produced more amnesia than analge-
The primary afferent pain fibers are bipolar, and sia. Mothers often had no memory of the birth of their
their cell bodies are located in the dorsal root ganglia. babies when these techniques were used. In response to
The proximal axons of these neurons synapse in the these issues, a social movement against pharmacologic
dorsal spinal cord, where extensive sensory integration analgesia for childbirth gained popularity in the 1950s.
occurs. Many studies have been conducted on the role Objections to the pharmacologic treatment of labor pain
of gender and hormonal environment on pain sensa- have at times been embraced by the movement for
tion. The results of such studies are made more difficult womens equality on the basis that doctors (mostly male)
to interpret by the subjective nature of pain and cul- were taking womens childbirth experience away. These
tural and individual differences in pain reporting. There issues have largely dissipated as techniques available for
are likely gender-related differences in pain such that labor analgesia have become safer and now do not
women experience less pain in response to a given nox- induce amnesia or depression of consciousness.
ious stimulus than men but are more likely to report Psychoprophylaxis was popularized by obstetricians
that pain. Women are less sensitive to analgesia from Grantly Dick-Read and Fernand Lamaze. Their theories
-opioid agonists such as morphine when compared to were based on the concept that the pain of childbirth
men, whereas men are insensitive to -opioid agonists. was an unnatural symptom found only in Western cul-
Pain sensitivity is reduced in pregnancy. This reduction tures and was induced by fear of childbirth. Accordingly,
is likely hormonally mediated, as it occurs as early as the incorporation of relaxation techniques would allow
8 to 12 weeks gestation. women to experience childbirth without pain. There is
There are intrinsic inhibitory systems that are tonically some evidence that anxiety can potentiate pain. In some
active to reduce pain transmission. Two major inhibitory studies, nulliparous women who had attended classes in
pathways are mediated by the neurotransmitters norepi- psychoprophylaxis had slightly less pain than nulliparous
nephrine and serotonin. Noradrenergic fibers originate in women who did not. There was no difference for
the periaqueductal gray and other noradrenergic nuclei in women who had experienced childbirth previously.
the brain and project caudally to the dorsal horn of the These methods are useful in preparing parents for a
spinal cord, where they synapse on the presynaptic aspects potentially stressful event. Although there is great variety
Analgesia for Labor and Delivery 31
CLINICAL CAVEAT
Prepared childbirth may decrease stress and attenuate Table 4-1 Parenteral Opioids for Labor Analgesia
labor pain in nulliparous patients.
Drug Dose Duration PCA Administration
embedded in areolar fatty tissue, are what we perceive as there is a reduced incidence of intravascular catheter
epidural space. The posterior border of the epidural space placement using the lateral decubitus position. This is
is formed by the ligamentum flavum. The ligamentum likely due to a gravity-related increase of venous pressure
flavum is not one ligament, but is composed of two curvi- and intravascular volume in the sitting position. The posi-
linear ligaments fused in the middle (Fig. 4-1). In some tion of the patient has minimal, if any, effect on the spread
cases, there is no midline fusion, particularly at thoracic of the anesthetic solution injected into the epidural space.
levels. Once the patient is positioned, an intervertebral inter-
Epidural anesthesia for labor is performed with the space is selected. Any space below the L1L2 space is
patient in the sitting or the lateral decubitus position. acceptable. When determining the level of the inter-
Although the most common determinant for patient space to be used, the most common anatomic guide
positioning is the preference of the operator perform- utilized is the line joining the iliac crests. It is important
ing the block, we will review briefly the potential to remember that in the nonpregnant state, this line is at
advantages and disadvantages of the two positions. the L4L5 level, but in most pregnant women the line
Patient comfort and preference seem to divide between actually marks the L3L4 interspace.
the two options evenly although obese patients appear Following antiseptic preparation of the insertion site
to favor the sitting position somewhat more than the and local anesthetic infiltration, the epidural needle is
lateral decubitus. Fortunately, most anesthesiologists advanced until the tip is engaged in the ligamentum
also prefer their obese patients sitting for epidural flavum. It is important to identify and engage the needle
placement for better landmark identification. Flexion in the ligament initially, as this step reduces the possibil-
of the lumbar spine is adequate in most patients, ity of false loss of resistance and catheter misplacement.
regardless of whether they are sitting or on their side. Furthermore, advancing the epidural needle without a
Lumbar flexion may be improved by another 10 to 15 stylet through loose fat or connective tissue may result in
degrees in the sitting position if the patient is sitting coring and plug formation in the needle lumen. This in
cross-legged (Turkish or Indian style). The lateral turn blunts the loss-of-resistance response of crossing the
decubitus position provides more stability and may ligament and could result in inadvertent dural puncture.
lessen patient movement during the procedure. When Once engagement is achieved, a loss-of-resistance tech-
the patient is sitting, an assistant is often required to nique is used to determine the entry into the epidural
provide support and minimize patient motion. space. Whether it is air, saline, hanging drop, or any
It has been suggested that concealed aortocaval other ingenious method does not affect success or
compression may occur in the lateral decubitus position. complication rates: operator preference determines
This phenomenon probably occurs only in exaggerated the technique. Loss of resistance is not always clearly
flexion, and there is no evidence derived from fetal heart felt: this is perhaps related to the incomplete fusion of
tracing that uteroplacental flow or fetal well-being is com- the two parts of the ligamentum flavum and the resulting
promised in the lateral decubitus position. Some have relative thinness of the central part of the ligament.
speculated that the left lateral decubitus position may be Opinions differ as to whether the bevel of the needle
hemodynamically more advantageous. However, the posi- should be advanced parallel or perpendicular to the sagit-
tion of the patient is often determined by which side the tal plane. Some suggest parallel advancement decreases
fetal heart rate monitor is situated: the patient has to turn the incidence of headache if an inadvertent dural punc-
facing the monitor so the cables running from the moni- ture occurs. However, when the needle is inserted paral-
tor to the patient do not cross the sterile field. Finally, lel to the sagittal plane, it should be turned 90 degrees
once in the epidural space. This maneuver may increase
the possibility of inadvertent dural puncture because the
turning needle may act like a corkscrew.
Dura mater Once the epidural space is identified, a catheter is
advanced through the epidural needle. There are two
Ligamentum flavum
types of epidural catheter designs: open-ended single ori-
fice and closed-end multiorifice catheters. Closed-end
Interspinous ligament multiorifice catheters deposit local anesthesia over
a length of about 1 to 1.5 cm in two or three different
Supraspinous ligament directions and provide a more even spread of the
injected local anesthetic and perhaps a lesser likelihood
of uneven or unilateral block than a single orifice
Figure 4-1 Schematic drawing of the relationship between the
various ligaments encountered during epidural placement and the catheter. Catheter material is also varied: soft, flexible
dura. Note that the ligamentum flavum is formed by the fusion of catheters have gained popularity over the earlier rigid
two curvilinear ligaments. designs. It is more difficult to pass a soft, flexible
Analgesia for Labor and Delivery 33
catheter; however, intravascular placement or migration epidural catheter. An intravascular catheter should be
of these catheters is less likely than with rigid catheters. removed and replacedmost maneuvers recommended
True soft catheters, however, are all open-ended sin- to salvage the catheter (e.g., gradual withdrawal of the
gle orifice catheters. Soldering closed the end of the catheter with repeat testing using boluses of local anes-
catheters results in a hard tip which will penetrate any thetics with or without epinephrine) only delay analge-
vein situated adjacent to the orifice of the epidural nee- sia for the patient and predispose to local anesthetic
dle. Thus when avoidance of vascular injury is important toxicity.
(e.g., patients with marginal coagulation status), use of Continuous labor analgesia can be provided by an ini-
open-ended soft catheters may have an advantage. tial loading dose of an anesthetic (Table 4-2) followed by
Once the catheter is advanced 5 to 6 cm beyond the either a continuous infusion of a local anesthetic solution
tip of the epidural needle, the needle is carefully with- or intermittent boluses of a local anesthetic. Continuous
drawn and removed. Do not withdraw the catheter from techniques are the common clinical practice: these
the needle once the tip of the catheter is beyond the tip provide more even analgesia utilizing lower drug concen-
of the epidural needle; this may result in sheer or damage trations (0.0625% to 0.125% bupivacaine or 0.075% to
to the catheter. The catheter is secured with 3 to 6 cm 0.125% ropivacaine with 2 to 4 g/mL fentanyl, hydro-
left in the epidural space. The deeper the epidural space morphone 3g/mL, sufentanil 2g/mL, or 1 to 2 g/ml
from the skin, the more of the catheter should be left in clonidine at 8 to 12 mL/hr), producing good or excellent
the epidural space to prevent accidental dislodgement. quality labor pain relief with minimal motor blockade of
However, placement of the epidural catheter more than the lower extremities than with intermitted techniques.
4 cm into the epidural space increases the likelihood of a Drug administration is titrated according to patient
unilateral or patchy block, likely due to advancement of needs, and patient-controlled epidural analgesia may
the catheter away from the middle. After placement, the be used. With this technique, the epidural infusion is
catheter is then secured with an adhesive tape. administered with an epidural pump and can be pro-
The catheter is then tested for inadvertent intrathe- grammed for patient-controlled use. With this device, a
cal or intravascular placement. Testing for intrathecal continuous infusion of one of the previously mentioned
placement is based on the fact that the intrathecal anal- dilute analgesic solutions is administered at rates
gesic dose of local anesthetics and narcotics is about between 4 and 12 mL/hr, and a patient has access to self-
1
5 to 110 of the epidural dose. Between 30 and 45 mg administer boluses of 3 to 8 mL with lockout intervals
of lidocaine or 7.5 to 10 mg bupivacaine is used ranging from 5 to 10 minutes. There is some increase in
for this purpose. Onset of profound analgesia in patient satisfaction due to this technique, although no sig-
less than 5 minutes suggests intrathecal placement. nificant improvement in analgesia.
Detecting intravascular placement is more difficult. The A modification of epidural anesthesia is the combined
use of the classic approach of adding 15 to 20 g epi- spinal-epidural technique. After the epidural space is
nephrine to the test solution and observation for heart identified, a long pencil point spinal needle is advanced
rate (HR) changes is difficult in the laboring patient.
Maternal HR variability secondary to uterine contrac-
tions and associated pain make interpretation of HR Table 4-2 Epidural Infusions for Labor Analgesia
changes with epinephrine-containing test doses
difficult. This may be minimized by injecting the epi- Infusion
nephrine-containing test dose immediately at the
end of a contraction. Some believe that intravenous Local Anesthetic Opioid
Loading Dose Concentration* Concentration
administration of even this small dose of epinephrine
may decrease uteroplacental perfusion. However, at Bupivacaine 0.125% Bupivacaine Hydromorphone
this small dose, epinephrine would have predominantly or Ropivacaine 0.075% 0.0625% to 0.125% 3 g/mL
-adrenergic effects, and no clinical evidence exists to Hydromorphone or Ropivacaine
support this fear. The most sensitive and specific test in 10 g/mL 0.075% to 0.125%
Volume: 10 mL
laboring patients for detection of intravascular place- Bupivacaine 0.125% Bupivacaine Fentanyl 2 g/mL
ment of epidural catheters is the injection of 1 mL of air or Ropivacaine 0.075% 0.0625% to 0.125%
via the catheter while heart tones are continually moni- Fentanyl 5 g/mL or Ropivacaine
tored with a Doppler ultrasound probe placed over the Volume: 10 mL 0.075% to 0.125%
maternal precordium. This simple test is underutilized Bupivacaine 0.125% Bupivacaine Sufentanil 2 g/mL
or Ropivacaine 0.075% 0.0625% to 0.125%
in clinical practice. Sufentanil 1 g/mL or Ropivacaine
Should a catheter be shown to be intrathecal, it can Volume: 10 mL 0.075% to 0.125%
be used for continuous or intermittent subarachnoid
analgesia or it can be removed and replaced with an *Clonidine 1 to 2 g/mL may also be added with or without the opioid.
34 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
brought attention that a poor-quality block with restricted with neuraxial narcotic use. Local anesthetic toxicity,
spread and slow onset is likely to be due to a sub- even when the infusate is administered intravenously via
dural catheter. These catheters should be removed and a migrated catheter, is very rare with current low-dose
replaced. epidural infusions.
Intravascular placement was previously discussed.
However, it is important to recognize that a catheter may
migrate intravascular at any time during labor, and this CURRENT RESEARCH INTEREST
may result in loss of analgesia. Timely replacement is the What is the underlying mechanism of maternal pyrexia
best solution. associated with epidural analgesia?
Unilateral analgesia occurs in 5% to 10% of patients.
The most common reason is lateral migration of the
catheter. Withdrawal of the catheter 1 to 2 cm may be Maternal temperature rises gradually during epidural
attempted followed by administration of a bolus of an analgesia. The temperature rise is usually noticed hours
anesthetic solution. Should analgesia remain unilateral, after placement of the epidural and is not associated
replacement of the catheter is the best option. with any infectious event. The etiology remains unclear.
However, recognition of this phenomenon is important
Indications, Contraindications, Complications, in preventing unnecessary diagnostic and therapeutic
and Caveats interventions in the mother and the newborn.
Epidural anesthesia is indicated at any stage of labor Common postpartum maternal complications include
when the laboring woman desires analgesia. It was postdural puncture headache, pain at the epidural inser-
shown to be the most effective way of relieving pain tion side, and prolonged effects of the anesthetic agents
with the least amount of maternal and fetal side effects (motor block, sensory deficit, urinary retention). Rare
among the current choices for labor analgesia. The but serious complications include epidural hematoma,
American College of Obstetricians and Gynecologists has infection, granuloma, and arachnoiditis.
stated that barring medical contraindication, a patients In experienced hands, unintended dural punctures
request should be sufficient for epidural placement. with large epidural needles occur in approximately 1% of
Contraindications for epidural placement include patients, and the incidence of postdural puncture
coagulopathy, local infection at the planned site of inser- headache is between 70% and 80%. Several maneuvers
tion, patient refusal or inability to cooperate, and inade- have been attempted to prevent the onset of these
quate training or experience of the anesthetist. Relative headaches, including prophylactic blood patch and pro-
contraindications include mild to moderate coagulopa- longed maintenance of and saline infusion into the spinal
thy, systemic infection, increased intracranial pressure, catheter. These issues are addressed elsewhere.
history of spina bifida, and other lumbosacral neu- Fetal/neonatal side effects are relatively uncommon
romeningeal malformations, and uncorrected maternal with epidural anesthesia in the absence of maternal
hypovolemia. decompensation. Apgar and neurobehavioral scores,
umbilical artery pH, and base deficit are no different in
newborns of mothers with or without epidural anesthe-
CURRENT CONTROVERSY sia. No effect of the epidurals on postnatal bilirubin
What is the lower limit of platelet count when epidural
metabolism is seen.
placement remains safe? Or rather should we monitor
platelet function routinely or at least in select patients?
CURRENT CONTROVERSY
Is the continued use of intrathecal fentanyl justified,
Common maternal side effects include lumbar given the knowledge of their potential to cause signifi-
sympathectomy-induced hypotension, narcotic-induced cant fetal bradycardia?
pruritus, nausea, and urinary retention. Hypotension fol-
lowing epidural or combined spinal-epidural placement
is usually mild and easily treated. It is not prevented reli- Fetal bradycardia associated with subarachnoid opi-
ably by fluid loading, and excessive fluid loading may oids, given as part of the combined spinal-epidural tech-
slow labor. As such, the routine infusion of more than nique, was described. Rapid onset of maternal analgesia
250 to 500 mL crystalloid prior to epidural placement is resulting in a precipitous reduction of circulating -ago-
not recommended. Narcotics, whether administered nist concentrations may cause an unopposed increase
epidurally or intrathecally, slow or halt gastric emptying in uterine tone, leading to decreased uteroplacental
in about 80% of laboring patients, and oral intake of food perfusion and fetal bradycardia. Also, reduction in
or liquids should be strongly discouraged in association maternal blood pressure, particularly when the opioid
36 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
Paracervical Block
Caudal Anesthesia Anatomy and Technique
Anatomy and Technique The paracervical ganglion or Frankenhuers ganglion
Caudal anesthesia is a variant approach for epidural is located lateral and posterior to the cervicouterine
anesthesia. The epidural space is accessed via the sacral junction. Sensory nerve fibers from the uterine corpus,
hiatus. The patient is placed in the lateral decubitus posi- the cervix, and the upper vagina pass through the para-
tion, and the sacral cornua are identified. Following local cervical ganglion: these are the fibers conducting the
infiltration of the skin, a short beveled needle is passed painful sensation of the first stage of labor. Finger-guided
between the cornua at a 45 degree angle. The crossing of infiltration of the posterolateral aspect of the vaginal
the sacrococcygeal ligament is felt as a distinct loss of fornix results in adequate analgesia for the first stage of
resistance. The needle is then redirected cephalad and labor in about 75% of patients. A further advantage of the
advanced 1 to 2 cm farther. It is imperative not to paracervical block is the superficial position of the gan-
advance the needle farther to avoid inadvertent puncture glion: it is rarely deeper than 2 to 4 mm from the vaginal
of the dural sac. Position of the needle can be confirmed mucosal surface. The patient is positioned in the litho-
using the following tests. Injection of 3 to 4 mL of air tomy position with left uterine displacement. A needle
through the needle with simultaneous auscultation over guard is used to prevent the needle from penetrating
the thoracic spine will result in a characteristic whoosh deeper than 2 to 3 mm into the vaginal vault. This will
sound heard if the needle is correctly placed in the sacral minimize but not abolish the possibility of vaginal injury
epidural space. Rapid injection of 3 to 5 mL saline while or penetration of the fetal presenting part. The ganglia
palpating at the projected level of the tip of the needle are located at approximately 4 and 8 oclock positions
will reveal subcutaneous placement of the needle tip. just under the mucosa of the vaginal vault. Care should
However, this test will not differentiate between a nee- be taken by the operator not to put undue pressure on
dle in the caudal epidural space and one passed deep the mucosa with the examining finger, as this may distort
between the sacrum and the coccyx. Once the operator the anatomy and result in a failed block. After careful
is satisfied with the location of the needle, a soft catheter aspiration, 5 to 10 mL of local anesthetic solution is
is passed 4 to 6 cm into the sacral epidural space. Testing injected. There should be a 5 to 10 minute interval
and intrapartum management of the catheter are similar between the left- and right-sided blocks while the fetal
to that of a lumbar epidural catheter. heart rate is monitored. On occasion, fetal bradycardia
may result from a paracervical block, and fetal heart rate
Indications, Contraindications, Complications, monitoring is recommended during and after the
and Caveats procedure. 0.125% bupivacaine, 1% lidocaine, and 2%
Indications and contraindications are similar to those 2-chloroprocaine have all been used for paracervical
for lumbar epidural anesthesia. Caudal anesthesia is blocks. Epinephrine-containing solutions are AVOIDED.
superior for analgesia for the second stage of labor It seems that 2% 2- chloroprocaine is associated with the
because of proximity of the catheter to sacral nerve least amount of fetal side effects and the lowest reported
roots. It may be successful in patients in whom attempts neonatal local anesthetic blood levels while the duration of
to place an epidural catheter via the lumbar route have action is not remarkably different from the other local anes-
failed (prior back surgery, kyphoscoliosis, obesity). thetics. The duration of the block is about 30 minutes to 1
Side effects and complications are similar to those of hour, after which the block can be repeated as necessary.
lumbar epidural analgesia. An uncommon but serious
potential neonatal complication is inadvertent injection Indications, Complications, and Caveats
into the fetal head when the needle is accidentally The paracervical block is indicated for analgesia for
passed between the sacrum and the coccyx. the first stage of labor.
Analgesia for Labor and Delivery 37
Maternal complications are rare and avoidable. Using line and directed at 30 to 45 degree from the sagittal
small doses of dilute drugs can prevent systemic toxicity toward the vertebral body. Once bony resistance is identi-
from inadvertent intravascular injection of the local anes- fied, the needle is redirected so it just misses the anterolat-
thetic solution. Injury of the injection site with hematoma eral surface of the vertebral body. 10 to 15 mL 0.375% to
or abscess formation has been reported. The paracervical 0.5% bupivacaine with 1:200,000 epinephrine is injected
block has no effect on the duration or progress of labor. after careful aspiration. The procedure is then repeated on
Fetal complications are more common. The most the contralateral side. The onset time for the block is
common unwanted side effect of the paracervical block about 5 to 8 minutes, and the duration is approximately
is transient fetal bradycardia, which occurs in up to 3 to 6 hours. There is no associated motor block, as only
40% of cases. The etiology remains unclear. Fetal brady- the sympathetic fibers are affected. Some evidence sug-
cardia occurs 2 to 20 minutes after the injection of the gests that lumbar sympathetic blockade may accelerate
local anesthetic solution and resolves within 5 to 10 min- the first stage of labor.
utes. Fetal bradycardia is more common in patients who
had a nonreassuring fetal tracing prior to the block, and Indications, Complications, and Caveats
most obstetricians avoid using a paracervical block in Lumbar sympathetic block was used successfully for
such patients. Furthermore, although fetal bradycardia is analgesia in the first stage of labor in patients when prior
usually transient, the severity and duration of the brady- spine surgery precluded the use of epidural or spinal
cardia correlate with pre-existing fetal acidosis and analgesia. Reported cases and series are from trained
neonatal depression. individuals: these practitioners have a 75% to 100 % suc-
Severe fetal injury may result from direct injection of cess rate.
the local anesthetic solution into the presenting part. The most common side effect observed was maternal
This is more common when the block is performed dur- hypotension, which can be prevented by administering
ing advanced stages of cervical dilatation. 250 to 500 mL IV crystalloid solution prior to the block
The paracervical block is associated with a significant and/or by treating with sympathetic agonists.
risk for physician for needlestick injury. The needle and Inadvertent intravascular, epidural, or intrathecal injec-
the palpating fingers are in close proximity, deep in the tion of local anesthetic solution may lead to unwanted
vagina of a patient who may have difficulty staying side effects of systemic toxicity, high spinal anesthesia,
motionless. or postdural puncture headache.
To summarize, the paracervical block is clearly inferior The need for two separate injections, the unsuitability
to a continuous epidural or spinal technique, as it is only of the block for continuous techniques, and the lack of
effective during the first stage of labor. Sacral nerve roots ability to extend the block for the second stage of labor
that conduct pain during the second stage of labor are not have limited the use of lumbar sympathetic block in
affected with this technique. It has a well-recognized obstetric analgesia. However, familiarity with the block
potential to cause fetal bradycardia and should not be allows the anesthesiologist to relieve pain in patients
used in the presence of a nonreassuring fetal heart trace. with prior back surgery and instrumentation who other-
The risk of needlestick injury in the era of HIV and hepa- wise would not be able to receive the benefits of conduc-
titis C awareness has further reduced the popularity of tion anesthesia.
the paracervical block. However, it is a relatively easy
block to learn and to perform, and the only additional
equipment needed is an adjustable needle guard. It is Pudendal Nerve Block
clearly superior to systemic analgesics and may provide Anatomy and Technique
improved labor analgesia to women who cannot have The pudendal nerve provides sensory innervation to
neuraxial blockade for a variety of reasons. the mid to lower vagina, perineum, and vulva, and is
thus responsible for conduction of pain information dur-
ing the second stage of labor. The pudendal nerve origi-
Lumbar Sympathetic Block nates from the S2S4 segments of the spinal cord. In its
Anatomy and Technique initial course, it follows the sciatic nerve to the lesser sci-
Uterine and cervical visceral afferent fibers join the atic foramen just below the ischial spine. The nerve then
sympathetic chain at L2L3. Sympathetic blockade per- runs in the pudendal canal just lateral and inferior to the
formed at this level will alleviate pain of the first stage of sacrospinous ligament. It then branches into numerous
labor. terminal branches innervating the perineum.
The patient is placed in the sitting position. The L2 There are two approaches to block the pudendal
level is identified. Following local infiltration, a 3.5-inch nerve: the transvaginal and the transperineal. The patient
22-gauge needle is inserted 6 to 8 cm lateral from the mid- is placed in the lithotomy position. The operator places
38 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
a finger in the vagina or the rectum and identifies the Although there are many options for labor analgesia,
ischial spine and the sacrospinous ligament. In the trans- by far the most popular modalities are epidural and com-
vaginal approach, the needle is restricted by a needle bined spinal-epidural analgesia. They have the benefit of
guard. No more than 1 to 1.5 cm should protrude excellent efficacy and a low incidence of side effects.
beyond the guard. The needle is inserted into the vaginal The perfect labor analgesic, however, would also be rela-
mucosa and then directed toward the sacrospinous liga- tively noninvasive, inexpensive, and widely available.
ment. When the ligament is passed through, there is a The achievement of these objectives, combined with the
loss-of-resistance sensation. From 3 to 10 mL of local enormous recent progress in the safety and efficacy of
anesthetic solution is injected after careful aspiration. labor analgesia, would be a great boon for womens
When using the transperineal approach the needle is health.
inserted between the rectum and the ischial tuberosity
and is directed just inferior and lateral to the ischial spine
and sacrospinous ligament. The same amount of local CASE REPORT
anesthetic solution is deposited as with the transvaginal A 21-year-old woman G1P0 in active labor requests labor
approach. 0.5% bupivacaine, 1% lidocaine, 1% mepiva- analgesia. Her vaginal examination is 1 to 2 cm dilated.
caine, and 3% 2-chloroprocaine with or without epi- Contractions are occurring every 8 to 10 minutes. Discuss
nephrine can all be used for pudendal nerve block in options for analgesia. Is it different for G3P2 at 8 cm?
labor without any significant maternal or fetal side
effects.
SUGGESTED READING
Indications, Complications, and Caveats Andrews PJ, Ackerman WE III, Juneja MM: Aortocaval compres-
Pudendal nerve block is indicated for pain in the sec- sion in the sitting and lateral decubitus positions during
ond stage of labor. Administration of the block requires extradural catheter placement in the parturient. Can
considerable experience, and unilateral or bilateral fail- J Anaesth 40(4):320324, 1993.
ure of the block is common. Collier CB: Accidental subdural injection during attempted lum-
Loss of the bearing down reflex occurs in about bar epidural block may present as a failed or inadequate block:
a third of women following pudendal nerve block, and Radiographic evidence. Reg Anesth Pain Med 29(1):4551,
use of epinephrine-containing solutions accentuates this 2004.
unwanted effect. Systemic toxicity may result from inad- Friedlander JD, Fox HE, Cain CF, et al: Fetal bradycardia and
vertent intravascular injection: the close proximity of the uterine hyperactivity following subarachnoid administration
pudendal vascular bundle predisposes to this complica- of fentanyl during labor. Reg Anesth 22(4):378381, JulAug
tion. Absorption of local anesthetic from the injection 1997.
site is rapid and reaches peak in maternal and fetal blood Friedman EA, Sachtleben MR: Caudal anesthesia: The factors
within 10 to 20 minutes. However, neonatal well-being is that influence its effect on labor. Obstet Gynecol 13(4):
not or is minimally affected by a pudendal nerve block. 442450, 1959.
Other maternal complications include hematomas, Fusi L, Steer PJ, Maresh MJ, Beard RW: Maternal pyrexia associ-
which are rarely significant, and deep pelvic or subg- ated with the use of epidural analgesia in labor. Lancet
luteal abscesses, which are rare but serious. Fetal compli- 1(8649):12501252, 1989.
cations are mainly associated with direct needle trauma Merry AF, Cross JA, Mayadeo SV, Wild CJ: Posture and the spread
and injection into the presenting part. As the injection is of extradural analgesia in labor. Br J Anaesth 55(4):303307,
performed blind and in close proximity to the palpating 1983.
finger of the operator, needlestick injuries are common. Mulroy M, Glosten B: The epinephrine test dose in obstetrics:
The pudendal nerve block may be useful in a patient Note the limitations. Anesth Analg 86(5):923925, 1998.
presenting in advanced labor when neuraxial blockade is Palmer CM, Cork RC, Hays R, et al: The dose-response relation
too late. When successful, it is also an excellent supple- of intrathecal fentanyl for labor analgesia. Anesthesiology
ment for the pain of the second stage in patients who have 88(2):355361, 1998.
received paracervical or lumbar sympathetic blocks for Rosen MA: Paracervical block for labor analgesia: A brief historic
analgesia in the early part of their labor. Failure of the review. Am J Obstet Gynecol 186(5 Suppl Nature):S127S130,
block is perhaps its most common complication. 2002.
5
CHAPTER Fetal Monitoring
and Resuscitation
ANA M. LOBO
Fetal Stress Reactions Over 50% of all fetal deaths are associated with fetal
Antepartum Fetal Assessment asphyxia or maternal factors (i.e., pregnancy-induced
The Nonstress Test hypertension, placental abruption). Intrauterine hypoxia/
Contraction Stress test birth asphyxia accounts for 3% of perinatal deaths
Biophysical Profile while placental or umbilical complications are responsi-
Intrapartum Fetal Assessment ble for 2%. Fetal monitoring is one important vehicle by
Electronic FHR Monitoring which fetuses at risk may be identified and promptly
FHR Patterns treated, with the goal of reducing perinatal morbidity
Treatment of FHR Decelerations and mortality.
Fetal Scalp Sampling
Umbilical Cord pH
Fetal Pulse Oximetry FETAL STRESS REACTIONS
Fetal Electrocardiogram Monitoring
Ultrasound Both acute fetal distress and chronic fetal stress reac-
Newborn EvaluationThe Apgar Score tions are detected through fetal monitoring. Fetal oxygen
Fetal Respiratory and Circulatory Changes at Birth deprivation may result in various physiologic responses.
Neonatal Resuscitation These include vagal activity (bradycardia); tachycardia; a
Basic Newborn Care decrease in fetal breathing movements; gasping move-
Resuscitative Equipment ments; redistribution of blood flow to the brain, heart,
Chest Compressions and adrenals; increased circulatory catecholamines; and
Medications systemic hypertension.
Medication Administration Routes Acute fetal distress is the result of severe and/or pro-
Withholding Resuscitation longed deprivation of oxygen. Fetal hypoxia or asphyxia
Termination of Resuscitation may occur due to the delivery of a hypoxic mixture of
gases and/or a critical reduction of blood flow to the
During pregnancy and throughout labor and delivery, uterus. If severe, or prolonged, the preceding may result
both the mother and fetus are routinely evaluated, to in decreased fetal oxygen tension, increased carbon
decrease morbidity and mortality. A thorough under- dioxide tension, and respiratory and metabolic acidosis,
standing of fetal monitoring and resuscitation is essential leading to lactate accumulation. Fetal compensatory
to anesthetic practice, as the administration of anesthesia mechanisms may be inadequate, resulting in asphyxia
may profoundly affect maternal and fetal physiology and and permanent tissue damage. Urgent delivery may be
outcome. Information obtained through fetal monitoring indicated.
suggests how a fetus will tolerate labor, delivery, and Chronic fetal stress may lead to hypoxemia, which
anesthetic intervention and guides anesthetic manage- may or may not require immediate treatment. Factors
ment of the parturient. With the advent of improved which may cause chronic fetal stress include the follow-
monitoring techniques, perinatal mortality has decreased ing: fetal congenital anomalies, decreased hemoglobin con-
approximately 3% per year in the United States since 1965. centration (i.e., hemolytic disease), inadequate maternal
39
40 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
oxygenation (i.e., asthma, pulmonary disease), decreased ther fetal assessment to ensure fetal well-being. Tests
placental oxygen delivery (i.e., maternal hypertension, used to further evaluate the fetus include the nonstress
heart disease, smoking, diabetes, anemia) or decreased test, the contraction stress test, and biophysical profile
placental oxygen transfer (i.e., placental abruption, pla- scoring.
centa previa), and inadequate maternal nutrition (i.e.,
excessive narcotic, alcohol use). Some of these factors
may be controlled with specific maternal interven- The Nonstress Test
tions that minimize fetal stress, thereby decreasing The nonstress test (NST) is frequently used as an initial
the need for immediate obstetric treatment. Routine screening test in the high-risk parturient to evaluate fetal
antepartum fetal assessment and evaluation, as well well-being. It is noninvasive and has no contraindications.
as intrapartum fetal monitoring techniques, are critical Normally, fetal movement is associated with temporary
because they detect fetal stress, thereby preventing poor accelerations in fetal heart rate (FHR) which occur at fre-
maternal and fetal outcome. quent intervals. Infrequent movement not associated with
FHR accelerations may indicate a compromised fetus.
During a NST, the baseline heart rate and long-term vari-
ANTEPARTUM FETAL ASSESSMENT ability (discussed later) of the FHR tracing are also
evaluated. A normal baseline FHR is between 110 and
Antepartum fetal assessment incorporates various 160 beats/min (bpm). Bradycardia may suggest fetal
tools which monitor and evaluate maternal and fetal hypothermia, congenital heart block, exposure to a
well-being. A detailed explanation of routine prenatal -adrenergic receptor antagonists, and acute fetal hypoxia.
evaluation and care is beyond the scope of this chapter. Fetal tachycardia (FHR > 160) may reflect maternal fever,
Pregnancy dating and fetal growth evaluations are part chorioamnionitis, fetal exposure to anticholinergics or
of routine care. Additional indicators of fetal well- -adrenergic agonists, fetal anemia, or fetal hypoxia.
being include estimations of fetal movement. After 28 Normal long-term variability is present when the FHR trac-
weeks gestation, normal fetuses have gross body move- ing demonstrates a sinusoidal wave pattern which cycles
ments 20 to 50 times/hr, although quiet times lasting every 3 to 6 minutes (Fig. 5-1).
20 to 75 minutes occur. A change in movement pattern The parturient lies in the Semi-Fowlers position, tilted
(appreciated by the parturient) may indicate a need for to the left, for 20 minutes. Fetal movements are detected
further fetal evaluation. Lack of movement may reflect by maternal report, and the FHR tracing is recorded using
fetal hypoxia or asphyxia requiring immediate inter- an external monitor. The tracing is evaluated for FHR
vention. Parturients at high risk for fetal compromise accelerations immediately following fetal movement.
(i.e., postdate gestation, diabetes, pregnancy-induced A normal, or reactive, NST requires that the FHR be in the
hypertension, premature labor, etc.) may require fur- normal range, that two or more fetal movements occur
Figure 5-1 Presence of short- and long-term variability in a normal FHR tracing.
Fetal Monitoring and Resuscitation 41
Normal FHR Absent FHR Inconsistent late Uterine contract <3 uterine contract
variability FHR decelerations >q2 min in 10 min
Findings 3 contract/10 min Persistent late Variable FHR Uterine contract Poor recording
Contract last 40 sec FHR decelerations decelerations last >90 sec cause quality
No late decelerations Abnormal late FHR decelerations
baseline FHR or fetal bradycardia
Actions Repeat in 1 week BPP BPP Repeat in 24 hr Repeat in 24 hr
BPP if indicated Consider delivery Repeat in 24 hr
42 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
From Manning FA: Fetal biophysical profile scoring: A prospective study in 1,184
Electronic FHR Monitoring high-risk patients. Am J Obstet Gynecol 140:289294, 1981.
Continuous electronic FHR monitoring provides an box (*) represents 10 seconds of time in the longitu-
ongoing tracing of the FHR from early labor through dinal axis, while the bolder lines () divide the grid into
delivery. This method of FHR monitoring is the corner- 1-minute time intervals. The bottom grid displays the
stone for evaluation of fetal well-being. The continuous presence and duration of contractions. When a tocody-
FHR tracing and uterine contraction pattern are namometer is used (i.e., internal monitoring), the verti-
recorded on the fetal monitoring strip (Fig. 5-2). The cal axis measures uterine contraction intensity (in mm
top grid is used to record FHR over time. Each small Hg). Two techniques of electronic FHR monitoring are
From Manning FA: Fetal assessment based on fetal biophysical profile scoring experience in 19,221 referred high-risk pregnancies. II. An analysis of false-negative fetal
deaths. Am J Obstet Gynecol 157:880886, 1987.
EGA, Estimated gestational age; L/S, lecithin/sphingomyelin.
Fetal Monitoring and Resuscitation 43
currently in use: external (or noninvasive) and internal demonstrates a nonreassuring FHR pattern. Use is
(or invasive). limited by a maternal history of herpes, hepatitis C,
External FHR monitoring involves placement of both and/or HIV disease, as fetal transmission may occur.
a Doppler ultrasound transducer (measuring FHR) and a Internal uterine contraction monitors are used to
tocodynamometer (identifying uterine contractions and evaluate the duration, intensity, and quality of uter-
their duration) over the gravid uterus. The Doppler ultra- ine contractions. An open-ended, fluid-filled, plastic
sound transducer identifies fetal cardiac events over catheter is placed in the uterine cavity, and the pres-
time, but does not accurately reflect beat-to-beat vari- sure generated by each contraction is converted to and
ability (described later). Both FHR and uterine contrac- electric signal and recorded on the strip. Contractions
tion presence and duration are simultaneously recorded which generate 60 mm Hg of pressure and last 60
over time on the FHR/uterine contraction strip. External seconds are generally considered adequate to dilate the
monitors are easy to use and noninvasive in design but cervix.
are less sensitive than internal monitors. Internal monitoring is useful in the diagnosis of
Internal FHR monitoring is more invasive but most delayed labor progression, secondary to inadequate con-
sensitive in evaluating FHR patterns, FHR variability, tractions, and uterine hyperstimulation (which may lead
and intensity of uterine contractions. A small electrode to fetal distress, placental abruption, and/or uterine rup-
is inserted via the cervix onto the fetal presenting part. ture). It can also be utilized as an adjunct to pitocin
Placement requires that the cervix be at least 1 cm administration for labor augmentation or induction.
dilated, the presenting part be vertex or breech, the
fetal head be well applied, and membranes be rup- FHR Patterns
tured. Internal monitors are more accurate, have fewer There are two types of FHR patterns: the baseline FHR
artifacts, and are sensitive in recording fetal heart rate (i.e., FHR in the absence of a contraction) and the peri-
beat-to-beat variability (see later). They are indicated if odic FHR (i.e., FHR changes associated with uterine con-
the external monitor tracing is of poor quality and/or tractions).
44 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
Figure 5-3 A flat FHR tracing. Minimal/absent short- and long-term variability.
Fetal Monitoring and Resuscitation 45
below baseline. These decelerations are the result of mild uterine contraction. The nadir of the FHR is observed
fetal hypoxia or head compression (temporary increase in after the contraction peak and recovery of the FHR is
intracranial pressure) leading to reflex vagal stimulation. If observed following the end of the uterine contraction
mild, they are usually benign and well tolerated. Early (Fig. 5-7). Late decelerations are classified as either
decelerations are rarely severe in nature, and further evalu- reflex- or nonreflex-based upon their etiology. Reflex
ation of fetal status is usually not indicated. late decelerations typically occur secondary to maternal
Variable decelerations in FHR are the result of umbili- hypotension (causing decreased uterine blood flow,
cal cord compression leading to vagal stimulation and cerebral hypoxia, increased fetal vagal tone, and FHR
bradycardia. Typically, they are irregular in intensity and deceleration). Typically, the FHR maintains good short-
duration and nonuniform in shape (Fig. 5-6). They are term variability throughout the deceleration, and the
variable in onset, severity, and duration. Not infrequently, FHR returns to baseline with resolution of the contrac-
the FHR drops dramatically with the onset of a contrac- tion. Correction of maternal hypotension normalizes
tion (as the umbilical cord is compressed), and recovery the FHR pattern. Conditions such as pre-eclampsia,
is variable. If severe, meaning a FHR drop of 60 bpm intrauterine growth retardation, and repetitive late
below baseline and/or lasting >60 seconds, these vari- decelerations may result in prolonged fetal hypoxia and
ables may progress to late decelerations. Often, variables lead to fetal myocardial depression, causing nonreflex
will improve by changing the parturients position (i.e., late decelerations. Progressive decompensation of fetal
left uterine displacement) and administering oxygen. cardiac function is the result of inadequate fetal oxygen
A normal fetus is usually able to tolerate mild to moder- supply during contractions. Poor or absent short-term
ate variable decelerations for a period of time without FHR variability is present.
being compromised. Terminal fetal bradycardia refers to a severe, pro-
Late decelerations, caused by uteroplacental insuffi- longed decrease in FHR (Fig. 5-8). FHR typically falls
ciency, contour and mirror the uterine contraction below 60 bpm without prompt recovery. Not infre-
curve. Characteristically, the FHR begins to decelerate quently, beat-to-beat variability is diminished or absent.
approximately 10 to 20 seconds after the onset of the This type of deceleration may suggest a hypoxic insult to
Fetal Monitoring and Resuscitation 47
States. For the most part, the values obtained correlate A study by Luttkus et al.1 calls into question the
with fetal scalp samples obtained shortly before birth. diagnostic power and technology precision of the FPO.
Umbilical cord blood pH values may be used to evaluate One hundred seventy (170) fetuses with nonreassuring
whether low Apgar scores were the result of fetal FHR tracings were evaluated. Fetal blood samples (blood
hypoxia or if poor outcome was caused by another gas analysis and lactate analysis) and distribution and
factor. duration of desaturation periods to <30% were com-
pared for those fetuses defined as being academic. The
authors found an overestimation of FPO in the low range
Fetal Pulse Oximetry
of saturation values and an underestimation of FPO val-
Fetal pulse oximetry has emerged as a newer tech- ues in the higher ranges of saturation. Thus, the authors
nique to evaluate intrapartum fetal oxygenation. conclude, the advantage of FPO is limited by its diagnos-
Currently, it remains an adjunct to electronic FHR moni- tic power and technology precision.
toring. The fetal pulse oximeter (FPO) is currently being In a separate study, the same authors2 suggest that
used when the electronic FHR monitor shows a nonreas- simultaneous monitoring with a combination of fetal
suring tracing or if the tracing is unreliable (i.e., fetal ECG and FPO is feasible and reliable in indicating signs of
arrhythmia). intermittent hypoxia. They suggest that development of
Basically, the obstetrician places the FPO sensor technology combining these two modalities of fetal mon-
through the cervix so that it lies alongside the fetal cheek itoring may be encouraged as a result of their findings.
or temple. Operator placement skill is important to Recently, Nellcor Perinatal (manufacturer of the FPO)
ensure an accurate saturation reading. Membranes must addressed obstetricians regarding 13 case reports in
be ruptured for adequate placement. The FPO provides which parturients with an ominous FHR tracing, but a
continuous fetal arterial oxygen saturation readings on a FPO reading >30%, had poor neonatal outcomes. In this
beat-to-beat basis. communication, the manufacturer recommends deliv-
When compared with the adult, the fetus has fetal ery of the fetus in the presence of an ominous tracing,
hemoglobin and lower oxygen saturation. Fetal O2 satu- even if FPO values are normal. Thus, the accuracy of
ration between 30% and 70% is considered normal. fetal pulse oximetry may be inadequate in the diagnosis
Saturation readings consistently <30% for a prolonged of fetal acidemia, when the FHR tracing suggests an
period of time (10 to 15 min) are suggestive of fetal ominous pattern.
acidemia. Fetal blood scalp sampling and/or prompt
obstetric intervention may be indicated.
Fetal pulse oximetry was introduced with the hope Fetal Electrocardiogram Monitoring
that it would complement electronic fetal monitoring Fetal ECG monitoring may also be used as an adjunct
(given its limitations in predicting fetal compromise) to EFM. Fetal hypoxemia during labor can alter the shape
with the goal of preventing unnecessary cesarean deliv- of the fetal ECG. Changes may be seen in the relation of
eries. A randomized study performed over 2 years involv- the PR to RR intervals, and ST segment elevation or
ing 1011 laboring women with nonreassuring EFM depression may occur. A recent review of trial data
tracings found >50% reduction in cesarean deliveries involving 8357 women supports the restricted use of
performed (on patients monitored by EFM and FPO) fetal ST segment analysis in those fetuses displaying a
because of nonreassuring fetal status. However, the over- nonreassuring electronic FHR tracing to improve fetal
all cesarean delivery rate (secondary to all causes) was outcome. The major disadvantage of fetal ECG monitor-
not reduced because of an increase in the amount of ing is that it requires an internal scalp electrode.
cesarean deliveries performed because of dystocia. A new fetal monitoring system, the STAN method,
Overall section rate, therefore, was not changed by use combines electronic FHR monitoring and fetal ST analy-
of the FPO. sis. Recent Swedish multicenter randomized controlled
As of September 2001, the American College of trials involving 6826 women showed improvement in
Obstetrics and Gynecology failed to endorse the use of perinatal outcome when using combined intrapartum
the FPO in clinical practice. Concerns regarding escala- cardiotocography (CTG) with fetal ST segment wave
tion in medical care costs outweighing improvement in form analysis compared with CTG alone. This new moni-
clinical outcome were expressed. Currently, studies toring methodology may reduce fetal exposure to intra-
that address cost effectiveness are not conclusive. partum hypoxia and decrease the number of operative
A randomized clinical trial involving 10,000 women deliveries for fetal distress. The most important finding
with the goal of measuring the effect of FPO as an of this randomized controlled trial is a significant reduc-
adjunct to EFM on overall cesarean delivery rate is tion in fetal metabolic acidosis at birth (0.7%) in the
being initiated. fetuses monitored with both CTG and ST analysis
50 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
Newborns are normally cyanotic at birth. Prompt res- in its transit through the vaginal canal pushes approxi-
olution of this cyanosis occurs with normal ventilation mately two-thirds of the remaining pulmonary fluid
and adequate perfusion. A cold delivery room environ- out of the lungs. Newborn capillaries and lymphatics
ment can cause peripheral vasoconstriction, resulting in remove the remainder of this fluid after birth. Newborns
cyanotic extremities. A pink newborn receives a score of delivered by cesarean section do not always benefit from
2 for color, whereas a persistently cyanotic child receives the aforementioned process and may have more diffi-
a score of 0. Hypovolemia and hypotension may result in culty establishing normal ventilation. Following delivery
a pale-appearing newborn. If a newborn remains cyan- of the thorax, normal infants take their first breath
otic despite adequate respirations and administration of within a few seconds. This is partially due to normal elas-
100% oxygen, acidosis and pulmonary vasoconstriction tic recoil of the lungs following birth. Up to 80 mL of air
may be present. Other causes may include hypoplastic is inspired with the first breath as a negative pressure of
lungs or congenital heart disease. 60 to 100 cm H2O is generated. A normal term neonate
The Apgar score quickly, reliably, and easily identifies has a tidal volume of 5 to 7 mL/kg and a respiratory rate
newborns who require resuscitation and thereby aims to of 30 to 60 breaths/min. Rhythmic ventilation is normally
reduce perinatal morbidity and mortality. This score also established approximately 90 seconds after birth and
has prognostic significance in terms of neonatal mortal- depends upon peripheral chemoreceptors, which nor-
ity. If a neonate shows progressive improvement in Apgar mally respond to low PO2 and low pH.
score, this evaluation should continue through every A comprehensive description of normal fetal circula-
5 minutes until a score of 7 is obtained. tion is beyond the scope of this chapter. At birth, fetal
Generally speaking, the 1-minute score relates to the systemic vascular resistance increases, left atrial pressure
degree of neonatal depression and need for resuscitation. increases, and foramen ovale flow decreases as the
Infants with scores >8 at 1 minute usually do not require umbilical cord is clamped and the low-resistance pla-
ventilatory assistance. Infants scoring 3 to 7 are mild to centa is removed from the fetal systemic circulation.
moderately depressed and usually respond quickly to Simultaneously, pulmonary vascular resistance decreases
mask ventilation with 100% oxygen. Severely depressed as the first breaths are taken. As a result, pulmonary per-
infants (score 0 to 2) usually require aggressive resuscita- fusion is instituted as >90% of the right ventricular out-
tion, including endotracheal intubation and cardiac mas- put perfuses the lungs. Physiologic closure of the
sage. Mortality within the first month of life is, generally foramen ovale occurs with pulmonary venous return
speaking, inversely related to both 1- and 5-minute Apgar into the left atrium. Until the foramen ovale is anatomi-
scores and increases in low-birth-weight infants. In addi- cally closed (several months after birth), any condition
tion, Apgar scores correlate with neurologic morbidity. increasing right atrial pressure may open the foramen
The incidence of neurologically abnormal infants varies ovale, causing a right-to-left shunt and cyanosis. With
inversely with both 1- and 5-minute Apgar scores. Low normal oxygenation and ventilation, arterial oxygen ten-
birth weight is also an extremely significant factor, sion and pH increase, the pulmonary vasculature dilates
increasing the incidence of neurologic abnormalities six- further, and pulmonary vascular resistance decreases.
fold in infants weighing <2000 grams. The right-to-left shunt through the ductus arteriosus
ceases.
Both the pulmonary and circulatory changes that nor-
FETAL RESPIRATORY AND mally occur at birth do so spontaneously, as an adaptation
CIRCULATORY CHANGES AT BIRTH for extrauterine survival. Failure of these physiologic
adaptations to occur may impede neonatal resuscitative
Understanding the respiratory and circulatory changes efforts.
that occur at birth underlies effective resuscitation of the
newborn. Fewer than 10% of newborns require active
resuscitation to establish adequate respiration, heart rate, Neonatal Resuscitation
color, and tone. Yearly, over one million neonatal deaths The ultimate goal of neonatal resuscitation is to reduce
are due to neonatal asphyxia. Implementation of basic perinatal morbidity and mortality. Both acute and chronic
resuscitative techniques may be the cornerstone to fetal asphyxia may result in cognitive impairment, devel-
improving neonatal outcome. opmental delay, organ failure, cardiomyopathy, bone
Normally, the fetal lung is filled with an ultrafiltrate of marrow depression, and/or ischemic encephalopathy
plasma produced by the lungs in utero. Most reabsorp- (cerebral palsy). Prompt evaluation and appropriate
tion of this fluid takes place with the onset of contrac- resuscitation are the cornerstone of newborn well-being.
tions and throughout the process of labor and delivery. Newborn resuscitation may be categorized into four
During the second stage of labor, squeezing of the thorax basic steps: rapid assessment/evaluation, establishment
52 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
of ventilation (via mask or endotracheal tube), chest despite the presence of meconium. It is important that
compressions, and fluid/medication administration. the newborn receive tracheal suctioning prior to posi-
Rapid assessment of the newborn includes the evalua- tive pressure ventilation, as this may cause meconium to
tion of breathing, color, heart rate, muscle tone, the travel down the respiratory tree.
presence of meconium staining, and a classification of Subsequent evaluation of respiratory effort, heart
gestational age. Routine care, including drying, warm- rate, and color may indicate that further resuscitative
ing, and airway clearing, may be the only necessary inter- efforts are necessary. Establishment of adequate ventilation
vention if the newborns assessment is normal. Some is the most important resuscitative maneuver. At birth,
newborns may require physical stimulation to improve regular respirations normally improve color, and heart
ventilation (back rubbing, flicking of the feet) and/or rate remains >100 bpm. Free-flow oxygen may be
oxygen administration. Most newborns only require the delivered. Assisted ventilation (via bag or mask) is indi-
preceding interventions. cated if gasping or apnea is present. Positive pressure
ventilation is also indicated if the heart rate remains
<100 bpm or if central cyanosis persists despite 100%
BASIC NEWBORN CARE oxygen administration. In newborns, inflation pres-
sures of 30 to 40 cm H2O (or higher) may be necessary
Basic routine newborn care is essential to newborn to establish visible expansion of the chest. Assisted
well-being. Hypothermia increases oxygen consump- ventilation should be delivered at a rate of 40 to 60
tion and may thereby make effective resuscitation breaths/min (30 breaths/min if chest compressions are
more difficult. Hypothermia is associated with respiratory being delivered). Administration of 100% oxygen is
depression. To maintain normothermia, newborns indicated to achieve normoxia (pink mucous mem-
should be delivered in a warm area and placed under branes and a normal oxygen saturation). Adequate
a radiant warmer. Thoroughly drying the skin and ventilation is established when bilateral chest expan-
wrapping the newborn in warm blankets helps prevent sion, breath sounds, and improvement in heart rate
heat loss. Newborns should be placed in a supine or and oxygen saturation are observed. Causes of inade-
lateral position with the neck slightly extended to quate ventilation include poor mask seal, airway
facilitate ventilation. Secretions should be suctioned to obstruction, and abnormal pulmonary anatomy (e.g.,
avoid airway obstruction. An 8 Fr or 10 Fr suction pulmonary hypoplasia, diaphragmatic hernia). Gastric
catheter should be used to clear secretions from the distention with prolonged mask ventilation may occur
mouth and then the nose. Care should be taken to avoid and compromise ventilation, at which point decom-
both deep suctioning (this may cause laryngospasm pression with an 8 Fr orogastric tube may be indi-
and/or vagal stimulation/ bradycardia) and prolonged cated. Assisted ventilation with 100% oxygen should
suctioning. Negative pressure should not exceed 100 continue if inadequate respirations or bradycardia per-
mm Hg. Meconium staining of the amniotic fluid sist. If the heart rate is below 60 bpm, chest compres-
requires intrapartum suctioning of the fetal nose, sion should be initiated and endotracheal intubation
mouth, and posterior pharynx prior to delivery of the performed. Traditionally, 100% oxygen has been uti-
body. This can be accomplished with a bulb syringe or a lized to correct hypoxia. Currently, preliminary evi-
large suction catheter (12 Fr to 14 Fr) and prevents dence suggests that lower oxygen concentrations
meconium aspiration (in a passive manner or as the may be utilized. However, the evidence currently avail-
newborn initiates spontaneous respirations). In utero able does not justify adopting this measure in a routine
meconium aspiration occurs in up to 30% of meconium- manner.
stained newborns. Tracheal suctioning should only be
performed in those newborns who are depressed (inad-
equate respirations, depressed muscle tone or bradycar- Resuscitative Equipment
dia). Direct laryngoscopy should be immediately The equipment used in newborn resuscitation must
performed prior to the initiation of spontaneous respira- be of appropriate size for successful intervention.
tions. Any residual meconium directly visualized from Ventilation bags for neonatal resuscitation are either self
the hypopharynx should be suctioned and intubation inflating or flow inflating and should be no larger than
performed. Further suctioning via the endotrachial tube 750 mL. The tidal volume delivered with each breath is
(ETT) should be accomplished as the ETT is withdrawn small (5 to 8 mL/kg). Face masks should seal around the
from the airway. This process should be repeated as mouth and nose and not cover the eyes or overlap the
necessary until little meconium is suctioned. Should chin. The mask should have a low dead space and prefer-
bradycardia persist or respirations remain depressed, ably have a cushioned rim to avoid excess pressure on
positive pressure ventilation may become necessary the face, while maintaining a good seal. At this time, the
Fetal Monitoring and Resuscitation 53
laryngeal mask airway may be used in the full-term compressions, as they may decrease the effectiveness
neonate when bag-mask ventilation is ineffective and of ventilation.
endotracheal intubation has failed. There are no studies There are two acceptable techniques for the deliv-
supporting its use in the presence of meconium, and its ery of chest compressions. The preferred technique is
use in small preterm neonates has not been adequately the two thumb-encircling hands technique. Two
studied. thumbs are placed on the lower one third of the ster-
For intubation, a laryngoscope with a straight blade num. They may be superimposed or adjacent to one
(size 0 for premature newborns, size 1 for infants) is another. The health care providers other fingers
used. The tip of the laryngoscope is inserted into the should circle the chest on their respective sides and
vallecula or under the epiglottis, and gentle elevation support the newborns back. Most providers prefer
(with or without cricoid) should bring the vocal cords this technique, as it appears to promote coronary per-
into view. The ETT should be of appropriate size and fusion and peak systolic pressures. In large newborns,
depth to result in adequate ventilation. ETT position the use of this technique may be limited. Another tech-
should be confirmed by checking for breath sounds nique used to deliver chest compressions in neonates
bilaterally over the chest and over the stomach. A CO2 is the two-finger technique. Two fingers from one hand
detector may be used if clinical assessment is not defin- are placed at a right angle to the lower one third of the
itive. If a stylet is used, it should not extend beyond the sternum. The providers other hand supports the
tip of the ETT. childs back. With respect to depth of compression,
Improvement in the color, heart rate, and activity of the current recommendation is to compress the ster-
the newborn is reassuring. Neonatal weight and gesta- num to one third the anterior-posterior diameter of the
tional age determine the ETT size and depth of ETT chest. In so doing, a palpable pulse should be gener-
insertion. Alternatively, depth of ETT insertion can be ated. If no pulse is appreciated, further compressions,
calculated by the following formula: weight (kg) up to one half the diameter of the chest may be deliv-
+ 6 cm = insertion depth at lip in centimeters (Table 5-6). ered. Producing a palpable pulse is the goal of chest
compression delivery. Compressions should be deliv-
ered smoothly and at a specific rate. The relaxation
Chest Compressions phase should be slightly longer than the compression
Chest compressions may be needed during resusci- phase so as to permit maximum blood flow throughout
tation of the newborn. In general, vital signs will be the body.
restored, in most neonates, once adequate oxygena- Chest compressions to ventilations should be deliv-
tion and ventilation are established. Persistent hypoxia ered in a 3:1 ratio. Thus, 90 chest compressions and
may result in generalized vasoconstriction and poor tis- 30 breaths are delivered per minute. Each three
sue perfusion and oxygenation. This may lead to acido- compression cycle should be followed by one breath.
sis, decreased myocardial contractility, bradycardia, Heart rate should be assessed every 30 seconds (i.e.,
and asystole. Currently, the indication for initiating carotid artery pulse, umbilical cord pulse, brachial artery
chest compressions, in most cases, is a heart rate of pulse). Discontinuation of chest compressions should
<60 bpm for 30 seconds, in the presence of adequate occur once the spontaneous heart rate is >60 bpm.
ventilation. Oxygenation and ventilation always takes
priority in the resuscitation of a neonate. This should
always be considered when tempted to start chest Medications
Medications are infrequently indicated during neona-
tal resuscitation. Generally speaking, the establishment
and provision of adequate oxygenation and ventilation
Table 5-6 Neonatal Weight, Gestational Age, ETT correct bradycardia in the newborn. Pharmacologic ther-
Size, and Depth of ETT Insertion apy is indicated for a spontaneous heart rate <60 bpm
despite adequate oxygenation/ventilation and chest
Depth of
Gestational ETT size, insertion from
compressions.
Weight (g) age, (weeks) mm (ID) upper lip (cm) Epinephrine is indicated when the spontaneous heart
rate is <60 bpm for 30 seconds, despite adequate ventila-
<1000 <25 2.5 6.5 to 7 tion and chest compressions and in the presence of a
1000 to 2000 26 to 34 3.0 7 to 8
2000 to 3000 34 to 38 3.5 8 to 9
systole. -adrenergic effects include vasoconstriction,
>3000 >38 3.5 to 4.0 10 which increases perfusion pressure during chest com-
pression. Thus, oxygen delivery to the heart and brain is
ID, Internal diameter. improved. -adrenergic stimulation results in enhanced
54 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
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Institute of Child Health and Human Development 1. Luttkus AK, Callisen TA, Stupin JH, Dudenhausen JW: Pulse
Research Planning Workshop for Standardizing oximetry during labourdoes it give rise to hope? Value of
FHR Tracing Definitions (1997) saturation monitoring in comparison to fetal blood gas sta-
tus. Eur J Obstet Gynecol Reprod Biol 22:110111, 2003.
Baseline FHR: Mean FHR rounded to increments of 5 2. Luttkus AK, Stupin JH, Callsen TA, Dudenhausen JW:
bpm during a 10-minute segment (excluding periodic Feasibility of simultaneous application of fetal electrocar-
changes, episodes of marked FHR variability) diography and fetal pulse oximetry. Acta Obstet Gynecol
Scand 82:443448, 2003.
bradycardia: FHR < 110 bpm
tachycardia: FHR > 160 bpm
Baseline FHR Variability: No distinction between SUGGESTED READING
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Dildy GA: A guest editorial: Fetal pulse oximetry. Obstet
FHR baseline fluctuations of 2 cycles/minute, Gynecol Survey 58(4):225226, 2003.
irregular in amplitude and frequency
Absent FHR variability: Undetectable amplitude East CE, Colditz PB, Begg LM, Brennecke SP: Update on intra-
range partum fetal pulse oximetry. Aust NZ J Obstet Gynaecol
Minimal FHR variability: > Undetectable amplitude 42(2):119124, 2002.
range: amplitude range 5 bpm Garite T, Nageotte M, Porreco R, Boehm F: Fetal pulse oximetry.
Moderate FHR variability: amplitude range 6 to 25 Obstet Gynecol 99(3):514515, 2002.
bpm Ibrahimy MI, Mohd Ali MA, Zahedi E, Tsuruoka S: A comparison
Marked FHR variability: amplitude range > 25 bpm of abdominal ECG and Doppler ultrasound for fetal heart rate
Acceleration: Sudden increase (onset to peak in <30 deceleration. Front Med Biol Eng 11(4):307322, 2002.
seconds) in FHR above baseline. FHR baseline change Kattwinkel J, Van Reempts P, Nadkarni V, et al: International
occurs if an acceleration lasting 10 minutes is present. guidelines for neonatal resuscitation: An excerpt from the
guidelines 2000 for cardiopulmonary resuscitation and emer-
Early Deceleration: Visually observed gradual decrease gency cardiovascular care: International consensus on sci-
(onset of deceleration to nadir 30 sec) in FHR with a ence. Pediatrics 106(3):e29, 2000.
return to baseline occurring with a uterine contraction.
The nadir of the deceleration coincides with the peak of Kilpatrick S, Laros Jr. RK: Fetal Evaluation: Routine and Indicated
the contraction. Tests. In Hughes SC, Levinson G, Rosen MA (eds): Shnider
and Levinsons Anesthesia for Obstetrics, Fourth edition.
Variable Deceleration: Visually noted sudden decrease Philadelphia, Lippincott, Williams and Wilkins, 2002, pp
(onset of deceleration to beginning of nadir < 30 sec- 613622.
onds) in FHR below baseline. FHR decrease 15 Kryc JJ: Evaluation of the Pregnant Patient: Preoperative
beats/minute below baseline and < 2 minutes from its Concerns. In Dewan DM, Hood DD (eds): Practical Obstetric
onset to return to baseline. Anesthesia. Philadelphia, W.B. Saunders, 1997, pp 1947.
Late Deceleration: Visually noted gradual decrease and Leszcynska-Gorzelak B, Poniedzialek-Czajkowska E, Oleszczuk
return to FHR baseline occurring with a uterine contrac- J: Fetal blood saturation during the 1st and 2nd stage of labor
tion. Respectively, the onset, nadir, and recovery of the and its relation to the neonatal outcome. Gynecol Obstet
deceleration occur after the beginning, peak, and ending Invest 54(3):159163, 2002.
of a contraction, in most cases. Levinson G, Hughes SC, Rosen MA: Evaluation of the neonate.
Prolonged Deceleration: Visually noted FHR decrease In Hughes SC, Levinson G, Rosen MA (eds): Shnider and
below the baseline of 15 bpm lasting 2 minutes but is Levinsons Anesthesia for Obstetrics, Fourth edition.
<10 minutes from onset to baseline return. Philadelphia, Lippincott, Williams and Wilkins, 2002,
pp 657670.
Quantification: All decelerations should be quantified
Lockwood CJ: Fetal pulse oximetry. Obstet Gynecol 99(3):
based on the depth of the nadir (bpm) below baseline
515516, 2002.
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the deceleration. Likewise, accelerations should also be Luttkus AK, Lubke M, Buscher V, et al: Accuracy of fetal pulse
quantified. oximetry. Acta Obstet Gynecol Scand 81(5):417423, 2002.
Neilson JP: Fetal electrocardiogram (ECG) for fetal monitoring
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fetal heart rate monitoring: Research guidelines for inter-
pretation. Am J Obstet Gynecol 177:13851390, 1997. Olofsson P: Current status of intrapartum fetal monitoring:
Cardiotocography versus cardiotocography and ST analysis
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of the fetal ECG. Eur J Obstet Gynecol Reprod Biol 110(1): Ugwumadu A: The role of ultrasound scanning on the labor
51135118, 2003. ward. Ultrasound Obstet Gynecol 19:222224, 2002.
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Fetal Asphyxia. In Hughes SC, Levinson G, Rosen MA (eds): heart rate patterns during the active phase of labor: The
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pp 623638. Williams KP, Galerneau F: Intrapartum fetal heart rate patterns
Sniderman SH, Levinson G, Gregory GA: Resuscitation of in the prediction of neonatal academia. Am J Obstet Gynecol
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Shnider and Levinsons Anesthesia for Obstetrics, Fourth
edition. Philadelphia, Lippincott, Williams and Wilkins, 2002,
pp 657670.
CHAPTER
6
Anesthesia for
Cesarean Delivery
JASON SCOTT
PAMELA FLOOD
57
58 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
tained, regional anesthesia has no negative effects on fetal The American Society of Regional Anesthesia
perfusion. Currently, the indication for cesarean delivery, (ASRA) has produced guidelines regarding the admin-
the urgency, the medical conditions of both mother and istration of regional anesthesia in patients receiv-
fetus, and the mothers wishes, will all influence the ing anticoagulant prophylaxis or therapy (Fig. 6-2).
choice of anesthetic technique. Anatomic abnormalities such as severe kyphoscol-
For most elective or urgent cesarean deliveries in iosis (with or without Harrington rod fixation) and
patients without an epidural in place, a spinal technique spina bifida may make regional anesthesia impossible
offers the best risk/benefit ratio. Blood loss at cesarean or impractical. General anesthesia is usually consid-
delivery may be less with a regional technique, though ered best in cases of severe maternal hemorrhage
studies in support of this finding have been criticized when fluid repletion is not possible prior to induction.
for selection bias because patients in whom excessive However, it is acceptable to use regional anesthesia in
blood loss is predicted are more likely to be selected for cases of placenta previa with no evidence of hypo-
general anesthesia. However, the avoidance of volatile volemiarecent studies do not support the idea that
anesthetic agents will eliminate these agents as a cause of blood loss is increased in these cases when regional
uterine atony postdelivery. Postoperative opioid require- anesthesia is employed.
ments are lower in those who have received axial opioids Local anesthesia in the form of abdominal field block,
than in patients who receive a general anesthetic. As a though not a first-line technique, may be useful in urgent
result, postoperative recovery is better with the mother cases when an anesthesiologist is unavailable. Local anes-
more mobile the next day, and better able to breast-feed thesia may also be a useful adjunct in cases of incomplete
and care for her baby. Fewer postoperative complications or patchy spinal or epidural anesthesia.
are likely to develop, such as pyrexia and chest infections.
There is also less depression in mothers both immediately
postpartum and at 1 week. If there are indications that the
PREOPERATIVE PREPARATION
surgery may be prolonged, a combined spinal-epidural
(CSE) technique can be used for anesthesia. In patients
with an epidural, the block can usually be used for Premedication
cesarean delivery. Epidurals may also provide an advantage Surgical delivery, whether planned or unplanned, can
in minimizing maternal hypotension, or when trying to be anxiety provoking for the parturient and her family.
avoid motor blockade of the thoracic segments and inter- Sedative drugs are not usually required in the parturient
costal muscles in patients with respiratory compromise, as about to undergo cesarean delivery, although this is a
the dose can be titrated to the desired sensory/motor level. good setting for psychoprophylaxis. Verbal reassurance
In cases of nonreassuring fetal assessment, the anes- and education are usually sufficient to facilitate the anes-
thesiologist and obstetrician must together weigh the thetic procedures. Benzodiazepines can cause amnesia,
severity of the fetal compromise against the maternal and most mothers wish to be able to remember the birth
risks of general anesthesia. General anesthesia may be of their child. Small doses of a benzodiazepine, such as
indicated for an emergency cesarean delivery. However, midazolam 0.5 to 2 mg intravenous, can be used to
clinical studies have shown that fetal outcome is not reduce maternal anxiety if nonpharmacologic methods
affected by the decision to administer regional anesthe- are not sufficient. An opioid such as fentanyl 25 to 50 g
sia in cases of moderate fetal distress. As such, in an intravenous may also be used to expedite painful proce-
emergency, the anesthesiologist must decide to proceed dures if required. If an oral route is preferred, 5 mg of
with general or regional anesthesia based on his or her diazepam 1 to 2 hours prior to surgery is an effective anx-
assessment of the likely speed of administration of the iolytic. Small doses of these drugs are safe and will pro-
anesthetic for each individual parturient. duce minimal fetal depression.
In parturients with medical illness, the nature and Occasionally, it may be appropriate to administer an
severity of the comorbid condition will influence the anticholinergic drug to reduce secretions and/or prevent
choice of anesthesia. Patients with a coagulopathy are at bradycardia induced by regional or general anesthesia.
increased risk for epidural hematoma after a regional Glycopyrrolate does not cross the placenta to the same
technique. extent as atropine and is the anticholinergic agent of
Low platelets are associated with pre-eclampsia, choice, although it should be noted that it retains the
HELLP syndrome, and other complications of preg- potential to reduce lower esophageal tone in the mother
nancy such as thrombotic thrombocytopenic purpura and thus theoretically increases the risk of aspiration. If
(TTP). Though controversial, most anesthesiologists regional anesthesia is used and the mothers airway
consider a platelet count between 80 and 100 109/L reflexes are maintained, this should not be problematic.
as a cutoff below which a regional technique is Aspiration of gastric contents during general anesthe-
contraindicated. sia has been a major cause of maternal morbidity and
60 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
Wait 10 t o 12 hr Wait >2 hr Resume Wait 10 t o 12 hr Wait >2 hr Resume
Low molecular*
weight heparin anticoagulants anticoagulants
Figure 6-2 Timing of neuraxial manipulation and anticoagulation (based on the American
Society of Regional Anesthesias [ASRA] Neuraxial Anesthesia and Anticoagulation Consensus
Statements. See complete guidelines [www.asra.com] for full details). *Based on prophylactic and
not treatment doses. Delays of 24 hours rather than 10 to 12 hours are considered appropriate on
bid dosing regimens. Consider delaying catheter removal for at least 24 hours after the last low-
molecular weight heparin (LMWH) dose. ASRA recommends that indwelling catheters be removed
before initiation of LMWH prophylaxis. Refers to patients receiving low-dose warfarin for
perioperative thromboprophylaxis, not chronic oral anticoagulation. Hold warfarin for an
international normalized ratio (INR) <3. Continue neurologic monitoring for 24 hours if INR < 1.5.
(From Wu CL: Regional anesthesia and anticoagulation. J Clin Anesth 13:4958, 2001.)
mortality. In 1986, a large Swedish study reported an aspi- should be performed when a difficult airway is not pre-
ration incidence of one in 661 cases of general anesthesia dicted. Gastric emptying with a nasogastric tube has been
for cesarean delivery, four times higher than the inci- utilized before general anesthesia in the parturient who
dence for nonobstetric surgery. However, in the last trien- has had a recent meal and requires urgent surgery. It is,
nial report on maternal death from the UK, there was however, unpleasant for the patient and does not guaran-
only one case of aspiration, and this complication tee either an empty stomach or reduced gastric acidity.
occurred in a woman with multiorgan failure in an Pharmacologic prophylaxis includes measures to
intensive-care setting. Other western countries have seen increase gastric pH and decrease gastric volume. A total
a similar decline in morbidity and mortality from gastric of 30 mL of 0.3 M sodium citrate will raise the gastric
aspiration. This success has been a result of the imple- fluid pH above 2.5 for 1 to 2 hours when given 15 to
mentation of several measures including recognition of 30 minutes prior to the induction of general anesthesia;
and preparation for difficult endotracheal intubation, however, there is no reduction in gastric volume.
NPO, nonparticulate-antacid preparation, and a reduction Nonparticulate antacids such as sodium citrate are pre-
in the use of general anesthesia for cesarean delivery. ferred, as particulate antacid aspiration results in pul-
A good preanesthetic assessment identifies patients at monary damage similar to that caused by acid aspiration.
greatest risk of difficult intubation and therefore aspira- Histamine H2-receptor antagonists, such as ranitidine,
tion. The most effective way to minimize the risk of aspi- will significantly reduce gastric acid secretion, reducing
ration is to use regional anesthesia and maintain a patent pH and, to a lesser degree, gastric volume. They have no
airway with intact reflexes. If regional anesthesia is con- effect on the volume or acidity of the gastric contents
traindicated, awake fiber optic intubation should be con- already present. Ranitidine 150 mg administered orally
sidered in the patient with an anticipated difficult airway. will take 60 to 90 minutes to exert an effect and has
Application of cricoid pressure and a rapid sequence duration of action of 6 to 8 hours. The recommended
induction and intubation with a cuffed endotracheal tube regimen is an oral dose at bedtime and in the morning for
Anesthesia for Cesarean Delivery 61
every 2 minutes after spinal injection with immediate mally. Showing the patient the capnographic tracing of
pharmacologic treatment of hypotension. her breaths or simply placing her hand on her upper
chest can be reassuring.
During the administration of both general and regional
Maternal Position anesthesia, pulse oximetry should be used as a quantita-
Aortocaval compression, also known as maternal tive method of assessing oxygenation; this is of particular
supine hypotensive syndrome, occurs when the preg- importance during the induction of general anesthesia.
nant woman lies supine. The etiology is multifactorial. The electrocardiogram (ECG) should be continuously dis-
The gravid uterus compresses the inferior vena cava and played during the administration of anesthesia for surgery.
the aorta against the bodies of the lumbar vertebrae. Many have noted, however, the surprisingly frequent
The decreased venous return may result in decreased occurrence of ST-depression after delivery of the infant
maternal cardiac output and blood pressure. Compression during cesarean delivery, one study noting an incidence
of uterine venous drainage results in an increased uter- of 25% in young, healthy parturients. The same study
ine venous pressure and therefore a reduced uterine noted that these changes did not occur during vaginal
perfusion pressure. Compression of the aorta or com- delivery, and transthoracic echocardiography did not
mon iliac arteries also results in a reduced uterine artery show any associated wall motion abnormalities or other
perfusion pressure. For these reasons, left uterine dis- indication of myocardial ischemia. Authors have specu-
placement must be maintained during cesarean delivery. lated on a number of etiologies, including tachycardia,
This can be effected by placing a wedge underneath the acute hypervolemia, coronary vasospasm, vasopressor
right buttock or tilting the operating table to the left by administration, and venous air/amniotic fluid embolism;
15 degrees. This practice results in a similar incidence of the exact cause remains unclear.
maternal hypotension and fetal bradycardia as that seen The detection of venous air emboli by Doppler
if anesthesia is performed in the lateral decubitus posi- ultrasonography has been advocated by some. The
tion. Adequacy of tilt can also be assessed by palpation method is extremely sensitive and detects venous air
of the left femoral artery while displacing the uterus to emboli of 0.1 mL or more in 30% of patients, so it is
the left; if the position is adequate, there should be no probably best reserved for use in patients with intracar-
significant increase in pulse quality. diac shunts. Chest pain, oxyhemoglobin desaturation,
and arrhythmias will diagnose significant venous air
embolism during cesarean delivery. Venous air embolism
Monitoring can be minimized by maintaining good intravascular
The American Society of Anesthesiologists (ASA) volume and maintaining 5 to 10 degrees of reverse
Standards for Basic Anesthetic Monitoring must be Trendelenburg position during surgery.
observed for all anesthetics, including those for cesarean In cases of severe cardiac disease or pre-eclampsia, it
delivery. First and foremost is Standard I: Qualified anes- may be useful to place a pulmonary artery catheter to
thesia personnel shall be present in the room throughout provide information on cardiac output and filling
the conduct of all general anesthetics, regional anesthetics, pressures. In the asleep intubated patient, noninvasive
or monitored anesthesia care. Standard II states that During methods of measuring cardiac output, such as trans-
all anesthetics the patients oxygenation, ventilation, circula- esophageal Doppler, may also be helpful.
tion, and temperature shall be continually evaluated.
During administration of general anesthesia, the con-
centration of oxygen in the patients breathing system REGIONAL ANESTHESIA FOR
should be measured with an oxygen analyzer with a low CESAREAN DELIVERY
oxygen concentration alarm operating. A method for
continual and quantitative measurement of end tidal General Considerations
CO2 should also be employed during general anesthesia. If there is suspicion of fetal compromise, oxygen should
Failure to detect CO2 after endotracheal tube placement be administered either by mask or nasal cannulae during the
signals esophageal intubation. In pregnant patients, it is administration of regional anesthesia to improve maternal
desirable to avoid hyperventilation, as acute respiratory and thus fetal oxygenation. A support person of the patients
alkalosis can cause a reduction in uterine blood flow. choice can also be present during the surgery to provide
Capnography is also used by many anesthesiologists comfort and emotional support. Many anesthesiologists pre-
to measure respiratory rate during regional anesthesia. fer to administer the regional anesthesia first and test the
Because a high thoracic sensory level is required in block, before inviting the support person into the room. It
cesarean delivery with regional anesthesia, some should be stressed that the guest must leave the room imme-
patients have the sensation that they are not breathing diately on request of the medical personnel, should admin-
because they cannot feel their chest rise and fall nor- istration of general anesthesia become necessary.
Anesthesia for Cesarean Delivery 63
A bilateral sensory block to T4 including sacral roots tion, but spread of anesthesia may be slower. One study
accompanied by motor block is generally accepted as found that the time from start of injection to completion
necessary for cesarean delivery. Zones of differential of anesthesia was similar in the sitting and lateral groups
blockade exist at the upper and lower edges of a regional because the more rapid identification of cerebrospinal
block. Loss of sensation to cold is two dermatomes fluid (CSF) in the sitting group offset the longer time
higher than loss of sensation to pinprick, which is in turn taken for the block to spread. If the lateral decubitus posi-
two dermatomes higher than loss of sensation to light tion is used, the right lateral decubitus position is pre-
touch. Loss of sensation to light touch from S1 to at least ferred to ensure a similar level of anesthesia bilaterally,
T5, and a dense motor block of hips and ankles are given that the patient will be positioned after anesthetic
good signs that anesthesia is adequate for surgery. The induction with left lateral tilt.
sensation of cold can be measured with ice or ethyl Lumbar puncture is performed at the L2L3 or L3L4
chloride spray, pin prick with a neurologic pin, and interspace. Smaller 25 to 27 G atraumatic pencil point
light touch with a nylon filament (Von Frey hair) or needles such as Sprotte or Whittacre result in headache
tissue. Measuring with these techniques is highly rates of >1% (Fig. 6-3). The selection of local anesthetic
anesthesiologist-dependent, and consistency of tech- depends on duration of surgery and the plan for postoper-
nique is important. ative analgesia (Table 1). Doses of bupivacaine required
Rates of onset and regression are different for spinal for spinal anesthesia during pregnancy are about 25% less
and epidural blockade. Alahuhta2 compared these rates than those required in nonpregnant women; venocaval
using pinprick. Spinal blockade rose to T5 by 10 minutes obstruction resulting in engorged epidural veins and
and peaked at T3 at 20 minutes and by 90 minutes had therefore decreased epidural and CSF volume probably
regressed to T9; it completely anesthetized the sacral contribute to this effect, and it is even more pronounced
roots. Epidural blockade reached a maximal height at in pregnancies with multiple fetuses. The dose of bupiva-
30 minutes and remained at T6 after 2 hours. In some caine used for cesarean delivery range from 7.5 to 15 mg.
cases, epidurals loaded with bupivacaine failed to com- The patients height and weight may affect the dose
pletely anesthetize the sacral roots. required though evidence for consistent variation is sparse.
After delivery of the baby and umbilical cord clamp- If the dose of bupivacaine is reduced to >10 mg with no
ing, intravenous oxytocin should be administered to the opioid the incidence of intraoperative pain is 70%.
mother to aid uterine involution and to reduce blood Isobaric solutions tend to spread farther and wear off
loss. Bolus oxytocin can cause maternal hypotension and faster than hyperbaric solutions in the nonpregnant popu-
tachycardia; 20 to 40 U of oxytocin should be diluted in lation. However, in pregnant patients subarachnoid injec-
1000 mL of crystalloid and run at 40 to 80 mU/min tions of 12.5 mg of both solutions have both been shown
(approximately 120 to 180 mL/hr). to reliably reach the upper thoracic dermatomes. The num-
In cases of refractory uterine atony, methylergonovine ber of milligrams of drug affects the block height rather
0.2 mg intramuscularly, or 15-methyl prostaglandin F2-alpha than the volume of injectant; no difference between final
0.25 mg intramuscularly may be required to enhance uterine block height or rate of onset was detected between 12 mL
contraction. Ergot derivatives may produce severe hyperten- of 0.125% bupivacaine and 3 mL of 0.5% bupivacaine. The
sion and occasionally coronary vasospasm, myocardial
infarction, or cerebrovascular accidents. In cases of life-
threatening hemorrhage, methylergonovine may be given
by slow intravenous bolus of 60 seconds or longer. The
prostaglandins may cause nausea, vomiting, diarrhea, fever,
tachycardia, tachypnea, hypertension, and bronchocon-
striction, and should be avoided in patients with asthma.
Spinal Anesthesia
Spinal anesthesia is popular because of its relative sim-
plicity, fast onset time, reliability, and density of block.
Technique
Patient position for administration of spinal blockade
can influence the rate of onset and spread of the drug,
but has little effect on the ultimate height of the block.
The sitting position is commonly used, as many anesthesi- Figure 6-3 Insertion of a 25-gauge spinal needle for an
ologists can perform a dural tap more easily in this posi- anesthetic for cesarian delivery.
64 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
quality and duration of the block may be improved by the Having inserted the epidural catheter, the catheter
addition of epinephrine 0.1 to 0.2 mg, though some con- should be aspirated observing for blood or fluid, and
troversy exists as to whether there is a prolongation of the then an epidural test dose may be administered. The
effects of lidocaine or bupivacaine. local anesthetic dose should be equivalent to the
intrathecal dose used for cesarean delivery (e.g., bupiva-
caine 7.5 to 12 mg or lidocaine 45 to 60 mg) to detect
Epidural Anesthesia inadvertent intrathecal administration. The addition of
Most cesarean deliveries performed under epidural epinephrine 15 g may help identify intravascular place-
blockade are urgent or emergent cases where the epidural ment as baseline heart rate increases by about 10 bpm,
catheter is in situ having been used for labor analgesia. though this test is not particularly sensitive or specific in
There remain some indications for the establishment de pregnancy. Some recommend the addition of 100 g of
novo of an epidural (see Choice of Anesthetic Technique fentanyl to the test dose, and patients may then report
section). the central effects of lightheadedness if the dose is
intravascular, though this may interfere with the assess-
Technique ment of the level of block. Air 1 mL combined with car-
Epidural catheters are usually placed at L2L3 or diac Doppler has also been put forward as a substrate for
L3L4 to avoid potential injury to the spinal cord from a test dose. A subdural block is harder to detect. It comes
unintentional dural puncture. In obese women, the sit- on relatively slowly (like an epidural block), usually
ting position often allows easier identification of the mid- extends higher than expected (may extend intracranially
line. Infiltration of the skin and subcutaneous tissues producing cranial nerve palsies), and is patchy. No tech-
with 1% lidocaine helps allow easy and pain-free inser- nique is completely reliable, and it should be remem-
tion of the Tuohy needle, and helps the mother to remain bered that catheters can migrate to a different space at
still and comfortable during epidural insertion. any time, so vigilance should be maintained whenever a
The midline approach is used by most anesthesiolo- drug is bolused through the epidural catheter.
gists, with the paramedian approach being used by some
practitioners in difficult patients, as there is less risk Dosing
of dural puncture. With the midline approach, the Between 3 and 5 minutes after the test dose there
epidural needle passes through skin, subcutaneous should be no evidence of motor blockade or dense sen-
fat, supraspinous ligament, interspinous ligament, and sory blockade (a band of anesthesia may be present in the
finally ligamentum flavum before entering the epidural upper lumbar and lower thoracic dermatomes), or hemo-
space. The epidural space is most often located using a dynamic disturbances. If this is the case, the therapeutic
loss-of-resistance technique. Either saline or air can be dose can be administered. The pregnant woman requires
used. Saline has been advocated as having a lower inci- approximately 1 mL of local anesthetic solution for each
dence of accidental dural puncture; however, this may level of anesthetic blockade. Therefore, a block to T4 will
make identification of a small dural puncture less reli- require 18 segments and usually 20 to 25 mL of local anes-
able. Glucose testing may give false positives as CSF thetic. We titrate the total dose in 5-mL increments of
drains into the epidural space. Both techniques are local anesthetic with at least 2 minutes between boluses.
acceptable, and anesthesiologists should use whichever The choice of anesthetic agent depends on the desired
technique is more reliable in their hands. Multiorifice speed of onset and the duration of action. Both lidocaine
Anesthesia for Cesarean Delivery 65
2% and bupivacaine 0.5% have durations of action that delivery and tubal ligation. Brownridge4 first described
should be sufficient for cesarean delivery (75 to 100 min combined spinal epidural anesthesia in 1981. He inserted
and 120 to 180 min, respectively). Lidocaine has a faster an epidural catheter at the L1L2 interspace, gave a test
onset of action, requiring about half of the onset time as dose, and then performed spinal anesthesia at the L3L4
bupivacaine. Bupivacaine 0.5% 10 mL + 10 mL given as a interspace. The technique has since been adapted by
two-stage top-up took an average of 42 minutes until block locating the epidural space with the Tuohy needle,
completion. Lidocaine, however, has been associated with inserting a long spinal needle through the Tuohy needle
a higher incidence of inadequate block. The addition of epi- into the subarachnoid space to deliver the intrathecal
nephrine to the local anesthetic to achieve a concentration dose of drug, and then passing the epidural catheter.
of 1 in 200,000 or 1 in 400,000 (0.1 mL or 0.05 mL of 1 in Success is improved when using a conic needle and feel-
1000 epinephrine) may decrease vascular absorption of the ing the dural puncture as a slight click.
local anesthetic and improve the quality and duration of the
block, and it is particularly efficacious when used with lido- The Sequential Block
caine. It is better to add the epinephrine just before giving Ten minutes after a spinal injection, 10 mL of epidural
the lidocaine epidurally, as this allows the solution to main- saline can produce a more cephalad spread of the block.
tain a higher pH and contains less sodium metabisulfate This has been confirmed by myelography to be a volume
than the commercially prepared lidocaine and epinephrine effect, a squeezing of the dural sac resulting in a decrease
solutions. The addition of 1 mEq of sodium bicarbonate to in CSF volume. This allows a smaller initial spinal dose to
each 10 mL of lidocaine 2% speeds the onset of action of the be used and then supplemented by injection into the
solution, making it comparable to 2-chloroprocaine 3%. epidural space. One advantage of this is that the length
Dosing a labor epidural for emergency cesarean delivery of time the mother is blocked after her cesarean delivery
means that a large dose of local anesthetic may have to be is reduced. Another advantage is a decrease in the inci-
given quickly, as there may not be time to dose incremen- dence of hypotension, though not all authors have found
tally. Lucas3 used 20 mL of whatever drug the patient had this benefit. A drawback of the technique is the fear of
been receiving with rapid and complete results in the producing a high or total spinal block. Volumes should
majority of mothers. There were no problems with high be limited to 5 mL every 5 minutes, with 10 minutes
blocksalthough there were some reports of loss of sensa- before the first injection. Care should be taken to assess
tion to cold in the cervical dermatomes in some cases. The the level of the block between each top-up.
block is assessed, and if there is any inequality then the
mother is placed in the full lateral position on that side and
given additional drug. Unless there has been a recent top-up Spinal Injection After Epidural Injection
of the epidural, 15 to 20 mL of local anesthetic is required. Placing a spinal block after an epidural block raises
Topping up in the delivery room is controversial but saves concerns about the production of a high or total spinal
time. Once the top-up has been given, it is imperative to block. However, in an audit of 72 spinal blocks after
stay with the mother and have a means of measuring her failed epidural anesthesia, in which half the women
blood pressure and administering appropriate vasopres- received 12.5 mg of bupivacaine, there were no reports
sors. Transfer to the operating room should be expedited. of high blocks. If spinal is being considered because an
Three percent 2-chloroprocaine has the fastest onset epidural has not been topped up, then a standard dose
of action but only a 40-minute duration of anesthesia. It should be considered. If it is to supplement an epidural
also decreases the subsequent efficacy of epidural opioid block that has failed to spread to the sacral or thoracic
analgesia. For these reasons, it is only really considered dermatomes, then 75% of the usual dose should be
for dosing of an existing labor epidural when time is of used and the mother positioned to control the height
the essence. Alkalinized lidocaine 2% with epinephrine of the block with pillows under the shoulders and head
is also a good choice for emergent cesarean delivery. In (Fig. 6-4).
Europe, an alkalinized mixture of 50:50 lidocaine: bupi-
vacaine with epinephrine is popular, combining rapid
onset with an improved quality of block and decreased Neuraxial Opioids
need for intraoperative supplementation. Epidural fentanyl improves intraoperative comfort
for the mother. Doses of 0 to 100 g of fentanyl have
been studied with 50, 75, and 100 g found to be
Combined Spinal-Epidural Anesthesia equally efficacious, providing 4 hours of postoperative
The combined spinal-epidural (CSE) technique is use- pain relief. Intrathecal fentanyl has been studied in
ful, as it both increases the reliability of the epidural and doses of 6.25 to 25 g. Doses over 20 g may increase
allows for prolongation of the block in cases of pro- the incidence of pruritus. Epidural morphine 3 mg is
longed cesarean delivery such as a tertiary delivery or efficacious for postoperative pain but takes about
66 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
local anesthetic from the drug mixture, a low potency The McCoy laryngoscope has a levering tip, which may
drug lot, or anatomic enlargement of the lumbar dural lift the epiglottis forward and aid in the visualization of the
sac. If delivery is urgent or the patient does not wish vocal cords. The laryngeal mask may be useful when there
to repeat the subarachnoid block, epidural or general has been a failure to secure the airway using a tracheal
anesthesia may be administered. If there is little or no tube. However, it does not prevent regurgitation of gastric
evidence of anesthesia, the spinal can be repeated with contents into the oropharynx, and cricoid pressure must
the same dose. If there is insufficient caudal spread, a be maintained unless this interferes with oxygenation.
sequential block may be suitable. Cricothyrotomy is the last resort when the patient
Failed epidural occurs in 2% to 6% of cases and is cannot be oxygenated any other way, and there are a vari-
caused by malposition or displacement of the epidural ety of packs available to perform this. Minitracheostomy
catheter, inadequate amount of local anesthetic, or sets are good because they are relatively easy to insert,
anatomic barriers to local anesthetic spread. Options the 15 mm connector will attach to the breathing circuit,
here include general anesthesia, repeat epidural, or spinal and the 4-mm internal diameter is sufficient to provide
injection. If the epidural is repeated, care must be taken oxygenation. In cases of a completely obstructed upper
not to administer a toxic dose of local anesthetic, as airway, resistance through the small diameter airway
often a large dose has already been given. Assessment for will result in hypoventilation, and the CO 2 will rise.
signs of local anesthetic toxicity is important. If a spinal A more definitive airway must be provided within 30 to
is chosen, the risk of high spinal anesthesia exists due to 45 minutes.
reduced CSF volume, and either a reduced dose should
be given or the procedure delayed before spinal injec-
tion. Parenteral analgesic drugs may be used for the treat- Induction of General Anesthesia
ment of breakthrough pain during regional anesthesia. Left uterine displacement should be instituted as
50% nitrous oxide (N2O), intravenous fentanyl 1g/kg, previously discussed. In nonpregnant patients, pre-
and intravenous ketamine 0.25 mg/kg are all useful oxygenation, otherwise known as denitrogenation, will
adjuncts because they do not greatly depress central air- allow approximately 3 minutes before oxygen saturation
way reflexes. Clinical judgment must be used to decide begins to fall. At term, there is an increase in oxygen con-
when supplementation has failed and general anesthesia sumption of 20%, a further increase of 20% during labor,
is required. and an increase of up to 100% over nonpregnant controls
during the second stage of labor. Therefore, desaturation
occurs much more rapidly in pregnant women. If the mask
GENERAL ANESTHESIA
is not tightly fitted, room air can enter, decreasing the effi-
cacy of denitrogenation. Normal tidal volume breaths for 3
Neither general anesthesia nor regional anesthesia
minutes will decrease alveolar nitrogen to 1%; four vital
(which is always accompanied by the potential need to
capacity breaths decrease alveolar nitrogen to 5%. The tidal
institute general anesthesia) should be considered in the
volume method buys about 15 seconds more time.
absence of a minimum equipment requirement. All equip-
ment must be checked regularly by a designated trained
person and must include the following: oxygen analyzer,
end tidal carbon dioxide (CO2) analyzer, ventilation dis- Rapid Sequence Induction
connect alarm, pulse oximeter, noninvasive blood pres- Cricoid pressure was first described by Sellick in 1961
sure monitor with a 1 minute cycle, ECG, suction, and a and is often referred to as Sellicks maneuver. He des-
tilting table. An assistant trained in applying cricoid pres- cribed a two-handed technique. The thumb and middle
sure is essential for airway management, and it is recom- finger of one hand are placed either side of the cricoid,
mended that there should also be the following (Fig. 6-5): and backward pressure compresses the esophagus on
One standard and one long-bladed laryngoscope the vertebral column at C6, thus occluding it. The other
A short-handled/polio blade laryngoscope (useful if hand is placed behind the neck, and forward pressure is
blade insertion is difficult) applied, placing the head in the sniffing position and
McCoy levering laryngoscope, which may improve a making the esophagus easier to occlude. In practice,
poor view at laryngoscopy or other noninvasive device when only one assistant is present, the second hand of
A gum elastic bougie and stylet the assistant is more usefully employed in reaching for
Tracheal tubes cut to the required length size 6 to additional equipment, and one-handed cricoid pressure
8 mm is most commonly used. If cricoid pressure is badly
Oral airways applied, it may make intubation more difficult.
Size 3 laryngeal mask It has been found that a constant backward pressure
A minitracheostomy set or the equivalent of 44 Newtons (N) will prevent passive regurgitation of
68 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
Consider/attempt LMA
Figure 6-5 Difficult airway algorithm. (a) Other options include (but not limited to): surgery utilizing face mask or LMA anesthesia, local
anesthesia infiltration or regional nerve blockade. Pursuit of these options usually implies that mask ventilation will not be problematic.
Therefore, these options may be of limited value if this step in the algorithm has been reached via the emergency pathway. (b) Invasive airway
access include surgical or percutaneous tracheostomy or cricothyrotomy. (c) Alternative noninvasive approaches to difficult intubation include
(but are not limited to): use of different laryngoscope blades, LMA as an intubation conduit (with or without fiberoptic guidance), fiberoptic
intubation, intubating stylet or tube changer, light wand, retrograde intubation, and blind oral or nasal intubation. (d) Consider
repreparation of the patient for awake intubation or canceling surgery. (e) Options for emergency noninvasive airway ventilation include
(but are not limited to): rigid bronchoscope, esopageal-tracheal combitube ventilation, or transtracheal jet ventilation.
Anesthesia for Cesarean Delivery 69
stomach contents. If vomiting occurs, cricoid pressure mediated by increased endorphin levels in pregnancy
should be released, as intraesophageal pressures could and is reversed by naloxone. Progesterone and its
otherwise lead to rupture. Cricoid pressure should be metabolites have anesthetic effects and may also con-
established before induction of anesthesia. Most patients tribute to the reduction in MAC during pregnancy.
will tolerate a pressure of 20 N, which should be increased Concerns about failure of uterine involution and subse-
after consciousness is lost. quent bleeding due to the presence of volatile anesthet-
ics led to the practice of using only 70% nitrous in
oxygen in the 1970s and 1980s. There followed a spate
The Failed Intubation of awareness cases. Now at least 0.5 MAC of inhalational
Careful positioning of the mother is important to agent is used in conjunction with 70% N2O to prevent
awareness.
optimize the chances of a successful intubation. This
Because of the lower blood/gas partition coefficients
includes adjusting the table height to one most comfort-
of the newer agentsisoflurane, desflurane, and sevoflu-
able for the anesthesiologist, placing pillows under the
raneit is easier to achieve 0.5 MAC rapidly following an
mothers head to provide support, good head extension
intravenous induction. Using a high initial concentration
on the neck, and ensuring that the mothers arms are not
(overpressure) and measuring the end tidal concentration
resting on her chest, as this may exacerbate difficulty in
facilitate rapid achievement of 0.5 MAC anesthetic at the
inserting the laryngoscope blade.
effect site.
If a failed intubation is encountered, it is important to
have a plan of action; failed intubation algorithms can be
useful for this. Failure to intubate the mother will cause Considerations for Maternal Ventilation
no harm as long as oxygenation can be maintained and
A higher oxygen concentration should be used during
passive regurgitation prevented. If intubation has failed,
cesarean delivery, as mothers have an increased meta-
a second dose of succinylcholine should not be given.
bolic demand. An inspired oxygen concentration of 50%
Repeated attempts at intubation will increase the chance
should be used with the woman in the left lateral tilt posi-
of aspiration, and in the presence of hypoxemia the sec-
tion. Mechanical hyperventilation may increase intratho-
ond dose may produce profound bradycardia.
racic pressure, exacerbating the effects of aortocaval
If it remains possible to maintain oxygenation and
compression, decreased venous return, and decreased
ventilation via a laryngeal mask or face mask, then a
cardiac output, and should be avoided. Furthermore, it
decision needs to be made regarding whether to awaken
has been shown that a maternal PaCO2 less than 27 mm
the mother. This will be based on an evaluation of the
Hg (3.6 kPa) results in vasoconstriction of the umbilical
mother and fetus, and the reliability of the airway. If the
vessels and fetal acidosis. Conversely, if the maternal
mothers life depends on completion of the surgery, as in
PaCO2 is allowed to rise above its term value of 31 mm
massive hemorrhage or cardiac arrest, then surgery should
Hg (4.1 kPa), the concentration gradient from fetus to
continue. In the case of sudden and severe fetal distress
mother is abolished, and the fetus may develop a respi-
with no recovery between contractionsfor example,
ratory acidosis.
with placental abruption or prolapsed cordand where
the airway is manageable, then to save the life of the InductionDelivery Interval
fetus it is reasonable to continue with anesthesia, though It is possible for the baby to become acidotic during
such an anesthetic may be extremely difficult. The inhala- the time from induction of anesthesia until delivery if pla-
tion agent should be increased to 2 to 3 times minimum cental perfusion is impaired or high concentrations of
alveolar concentration (MAC) in the spontaneously breath- N2O are used, resulting in diffusion hypoxia. Some evi-
ing patient, as light anesthesia may precipitate coughing, dence shows that higher concentrations of oxygen 60%
vomiting, and breath-holding. If the mothers life is deemed to 70% may improve the condition of the baby at deliv-
to be at risk, she should be awakened. In all other cases, the ery. If precautions against aortocaval compression and
safest course of action is to wake the mother and form an maternal hypotension are taken and a high FiO2 is used,
alternative plan. This will be spinal, epidural, or awake Crawford6 showed that an interval of up to 30 minutes
fiber-optic intubation. should not adversely affect fetal outcome.
All lipid-soluble anesthetic agents will cross the pla-
centa, and the longer the baby is exposed to a concentra-
Prevention of Awareness tion gradient the greater the uptake will be. Intravenous
There is a reduction in MAC of 28% in pregnant induction agents do not accumulate in the baby because of
women at 8 to 12 weeks gestation when compared to rapid redistribution into the larger maternal volume of dis-
nonpregnant controls, and this reduction in MAC is seen tribution. Maternal levels of inhalation agents are relatively
with all volatile anesthetic drugs. This effect may be constant, and a maternalfetal gradient will be maintained
70 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
Etomidate
ANESTHETIC AGENTS Etomidate causes less myocardial depression than
thiopental or propofol and less histamine release, mak-
Induction Agents ing it a good choice in patients with asthma or who are
When choosing an induction agent, one should con- hemodynamically unstable. It is partially hydrolyzed by
sider the preservation of maternal blood pressure and car- cholinesterases, found in high concentrations in the pla-
diac output, and thus umbilical blood flow, the avoidance centa, and its concentration in the fetal circulation after
of fetal depression, and also the reliability of maternal induction of anesthesia is less than with other agents. In
hypnosis and amnesia. a dose of 0.3 mg/kg, it produces rapid wakening in the
mother and good neonatal Apgar scores. Its major disad-
Thiopental vantages are pain on injection, myoclonic rigidity with
At a dose of 4 mg/kg, thiopental provides prompt involuntary movements, postoperative nausea and vom-
reliable induction of anesthesia, has few adverse effects, iting, and a reduction in plasma cortisol concentration in
and allows a smooth emergence from anesthesia. the baby at 1 hour of life, a potential disadvantage in an
Although it is detected in the umbilical vein, the circu- already stressed baby.
tion through the fetal liver protects the fetus from seda-
tion. At higher doses of 8 mg/kg, fetal depression does Midazolam
occur. The main advantage of thiopental is that while it Midazolam has limited use due to a slow onset of
doesnt produce neonatal compromise, it has a relatively action and side effects, which include neonatal hypother-
long duration of action when given at 4 mg/kg, and mia, hypotonia, jaundice, lethargy, respiratory depres-
may therefore help protect against early awareness at the sion, and poor feeding. It should be used for induction
time when the induction agent is wearing off and the only when there are contraindications to the use of other
end tidal concentration of volatile agent is rising toward agents. The induction dose is 0.2 mg/kg.
equilibrium.
unusual. Although all produce uterine relaxation and provide 20 to 30 minutes of muscle relaxation after suc-
decreased sensitivity to oxytocin, if used at 0.5 MAC fol- cinylcholine has worn off. Residual neuromuscular
lowing delivery, bleeding should not be a problem. blockade should be reversed at the end of the procedure
Sevoflurane and desflurane have lower blood solubility, with neostigmine and an anticholinergic agent, such as
allowing for very rapid induction and recovery from glycopyrrolate, to blunt the muscarinic side effects.
anesthesia, but no specific benefits over isoflurane have
been shown. Elevated serum levels of fluoride ions, a Interactions with Magnesium Sulphate
byproduct of sevoflurane metabolism, have been detected Patients receiving magnesium sulphate may not fas-
in babies 24 hours after anesthesia, without clinical ciculate after the intubating dose of succinylcholine,
sequelae. even though the action of succinylcholine is unaf-
fected. Magnesium sulphate also prolongs the neuro-
muscular blockade produced by nondepolarizing
Neuromuscular Blockers neuromuscular blockers. The phenomenon of recu-
Succinylcholine rarization may occur in mothers who have received
Succinylcholine, a depolarizing neuromuscular blo- magnesium sulphate, particularly those who remain on
cker, in a dose of 1 to 1.5 mg/kg, is the muscle relaxant infusions in the postoperative period. It is therefore
of choice for most patients. It is the only agent that important to monitor patients for signs of muscle
combines rapid onset, allowing intubation within 90 weakness for several hours postoperatively.
seconds, with rapid offset, allowing spontaneous respi- Opiates
ration to return 1 to 5 minutes after administration. It is Opiates rapidly cross the placenta to the baby and can
metabolized by pseudocholinesterase, and although potentially result in neonatal depression. For this reason,
concentrations of pseudocholinesterase are decreased they are not routinely used as part of a rapid sequence
by 30% due to a dilutional effect in pregnancy, this induction. They may, however, be used to help obtund
appears to be of little clinical significance. However, the hypertension and tachycardia associated with laryn-
there are a number of contraindications. The prevalence goscopy and intubation if this is considered appropriate;
of pseudocholinesterase deficiency in the population is a dose of 1 g/kg of fentanyl is considered safe for the
0.3%; the use of succinylcholine in these patients results neonate, but higher doses may cause respiratory depres-
in prolonged paralysis requiring postoperative ventila- sion. If opiates have been given to the mother prior to
tion. If succinylcholine is used in patients with burns, delivery of the baby, it is important to inform the pedia-
demyelinating neurologic conditions, or recent cord trician. This will prepare him for the possibility of respi-
transections, it can result in hyperkalemia. In patients ratory depression. After delivery of the baby and cord
with myotonia, succinylcholine may produce rigidity. clamping, opiates (100 to 200 g of fentanyl or 10 to 20
Finally, in susceptible patients, succinylcholine may trig- mg morphine) can be administered to the mother as part
ger malignant hyperthermia. A personal or family his- of the anesthetic, and to allow a smooth, pain-free emer-
tory of these condition should be elicited prior to gence from anesthesia.
induction of general anesthesia for cesarean delivery as Opiates should be continued for postoperative pain
for any surgery. control after general anesthesia. Patients receiving gen-
eral anesthesia for cesarean delivery seem to suffer more
Rocuronium
postoperative pain than those who received regional
Rocuronium, a nondepolarizing neuromuscular anesthesia for the procedure, despite using short-acting
blocker, at a dose of 0.6 mg/kg, can achieve intubating local anesthetics. Long-acting opioids such as meperi-
conditions at about 80 seconds. McCourt 7 found that dine or morphine can be given by intramuscular injec-
intubating conditions were significantly better after tion or intravenously via a patient-controlled pump.
a dose of 1 mg/kg, comparing more favorably with Nonsteroidal anti-inflammatory drugs, such as tenoxi-
succiny choline. The disadvantage of rocuronium is cam 20 mg intravenously, ketordac 15 mg intravenously,
that at these doses neuromuscular blockade lasts 50 to or diclofenac 100 mg pr, are good adjuncts to opiate anal-
60 minutes. gesia and reduce opioid requirements without adverse
effect to mother or baby.
Vecuronium and Atracurium
These nondepolarizing muscle relaxants are not well
suited to a rapid sequence induction, as even at CONCLUSION
relatively high doses they have an onset of action of
about 3 minutes. Atracurium, though not its isomer The modern anesthetic for cesarean delivery is
cisatracurium, also causes histamine release. Vecuronium regional rather than general in the large majority of cases.
0.05 mg/kg or atracurium 0.25 mg/kg can be used to As discussed, there are sound medical reasons for this
72 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
trend. These reasons are not limited to concerns about 5. Cooper DW, Carpenter M, Mowbray P, et al: Fetal and
the maternal airway and transfer of anesthetic drugs to maternal effects of phenylephrine and ephedrine during
the newborn. In addition to these issues are the psycho- spinal anesthesia for cesarian delivery. Anesthesiology
logical well-being of the parturient and her partner. 97(6):15821590, 2002.
Cesarean delivery is not the birth route of choice nor- 6. Crawford JS, James FM 3rd, Davies P, Crawley M: A further
mally, but a regional anesthetic can help to make the study of general anaesthesia for Cesarean section. Br J
birth experience family friendly. Often, the parents can Anaesth 48(7):661667, 1976.
experience the birth of their child together, and see and 7. McCourt KC, Salmela L, Mirakhur RK, et al: Comparison of
hold the baby nearly immediately after birth. With the rocuronium and suxamethonium for use during rapid
knowledge of the physiologic and pharmacologic sequence induction of anaesthesia. Anaesthesia 53(9):
changes in pregnancy, and importantly a supportive bed- 867871, 1998.
side manner, the obstetric anesthesiologist can provide a
safe and pleasant environment for what are the most
SUGGESTED READING
memorable days in many peoples lives.
Fernando R, Jones HM: Comparison of plain and alkalinized
local anaesthetic mixtures of lignocaine and bupivacaine
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7
CHAPTER Postcesarean Analgesia
FERNE R. BRAVEMAN
Introduction Hospital stays after cesarean delivery are longer than after
Postcesarean Analgesia vaginal delivery. A reduced length of stay following
Neuraxial Opioids cesarean section would be helpful to create beds for
Patient-Controlled Intravenous Analgesia newly delivered patients, as the size of postpartum units
Intramuscular and Subcutaneous Opioid Administration have not increased with the increase in the cesarean deliv-
Oral Opioid Administration ery rate! Nikolajsen1 has suggested that patients with
Nonopioid Therapies recall of severe postoperative pain are more likely to expe-
Multimodal Therapy rience chronic pain following cesarean delivery. This pain
Pain Therapies and Outcome can interfere with the patients daily activities. Better pain
control would minimize the occurrence of chronic pain
complaints.
INTRODUCTION
73
74 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
are often coadministered with opioids. Metoclopramide, Optimal epidural morphine administration is with 2 to
clonidine, and ondansetron have all been used as anal- 5 mg for a duration of action of 18 to 24 hours. Again,
gesic adjuvants for postcesarean analgesia, with varying lower doses were associated with a better side-effect
degrees of efficacy. profile. Longer durations of analgesia can be obtained
with PCEA. Some studies suggest PCEA is associated
with better analgesia and fewer side effects. 4 Longer
Neuraxial Opioids duration of action can also be achieved with a sustained
The large majority of patients undergoing cesarean release preparation of morphine (DepoDur), adminis-
delivery, as previously mentioned, have regional anesthe- tered as a single dose of 10 to 15 mg, which has a dura-
sia and thus will be administered neuraxial opioids. tion of analgesia of 24 to 48 hours.5
Short-acting opioids such as fentanyl and sufentanil pro- Meperidine, an opioid of intermediate lipid solubil-
vide improved intraoperative anesthesia but have little ity with local anesthetic properties, has been added to
effect on postoperative analgesia, unless administered spinal bupivacaine for intraoperative and early postop-
epidurally as a continuous infusion or via patient- erative analgesia. Ten milligrams intrathecally provides
controlled epidural analgesia (PCEA). Hydromorphone, approximately 4 hours of postoperative analgesia and
morphine, diamorphine, and meperidine have all been facilitates the transition to other forms of postoperative
administered for postoperative analgesia, all with good analgesia. A 50-mg dose administered epidurally pro-
analgesic results (Table 7-1). vides similar duration of analgesia and may be used to
Intrathecal morphine administered in doses of 0.1 to transition to other analgesics or as a bolus prior to begin-
0.4 mg provides a duration of analgesia between 18 to ning an epidural opioid/local anesthetic infusion or
24 hours. Yang 3 recommends the optimal analgesic PCEA.
dose of 0.1mg of morphine, administered with hyper- Short-acting opioids (e.g., fentanyl and sufentanil) are
baric bupivacaine. This dose is associated with a lower useful for postoperative analgesia as an epidural infusion
incidence of side effects and no greater pain relief than or PCEA. Bolus doses are short acting, thus not effica-
0.25 mg. The most frequent side effects are pruritus cious for postoperative analgesia. Table 7-1 provides
(up to 60% incidence) and nausea and vomiting. Studies guidelines for administration.
have not shown problems with hypoxemia or respira- Other opioids administered epidurally, although less
tory depression in this population. Side effects respond frequently, include butorphanol, methadone, and hydro-
to therapy (Table 7-2). Therapy should be included as morphone. The agonists/antagonist butorphanol is asso-
part of the postoperative orders to facilitate rapid treat- ciated with significant sedation, which makes its use
ment of side effects and greater patient satisfaction. in the obstetric population less popular than other
Ketorolac 15 mg IV/IM 4 to 6
Diclofenac 75 mg IM 12
100 mg PR 8
Ibuprofen 400 mg PO 3 to 4 First dose 3 hr
postoperative.
Clonidine 60 to 150 g Spinal Single dose Multimodal therapy
with spinal opioid
provides 6 hr of
analgesia.
Higher doses (alone
or with opioid)
have unacceptable
incidences of side
effects.
150 to 300 g Epidural Single dose In combination with
opioids, clonidine
will prolong the
duration of analgesia.
4 g/kg PO Single dose Give 1 hr
preoperatively.
Bupivacaine Varies Skin infiltration Can also be
administered via
a SQ infusion pump
(On-Q).
Postcesarean Analgesia 77
circumstances in which the patient has significant 3. Yang T, Breen TW, Archer D, et al: Comparison of 0.25 mg
comorbid disease, PCEA may be warranted. and 0.1 mg intrathecal morphine for analgesia after
cesarean section. Can J Anesth 46(9):856860, 1999.
4. Cooper DW, Ryall DM, McHardy F, et al: Patient controlled
CASE REPORT extradural analgesia with bupivacaine, fentanyl, or a mixture
of both after caesarean section. Br J Anaesth 176:611615,
A 26-year-old G2P1 patient is to undergo elective repeat
1996.
cesarean delivery. Discuss management as relates to
postoperative analgesia. 5. Hartrick CT, Manvelian G: Sustained-release epidural mor-
Spinal anesthesia is logical choice for intraoperative phine (Depodur): A review. Todays Therapeutic Trends
care. 22(3):167180, 2004.
For postoperative management, morphine 0.1 to 6. Ayoub CM, Sinatra RS: Postoperative analgesia: Epidural
0.2 mg with or without 25 to 50 g of clonidine can be and spinal techniques. In Chestnut DH (ed): Obstetric
administered with: Anesthesia, Third edition. Philadelphia, Elsevier Mosby,
Ketorolac 15 mg IV q6hr 24 hrs 2004, pp 480482.
Then oral Percocet or Vicoprofen beginning at 7. Sinatra RS: Post cesarean analgesia. In Birnbach DJ, Gatt SP,
approximately 24 hr Datta S (eds): Textbook of Obstetric Anesthesia. Philadelphia,
If CSE or epidural is used for surgical anesthesia, Churchill Livingstone, 2000, p 325.
postoperative management could be with 5 mg
DepoDur administered epidurally followed by 8. Wittels B, Glosten B, Faure EA, et al: Postcesarean analgesic
intravenous and oral therapy as above. with both epidural morphine and intravenous patient-
controlled analgesia. Neurobehavioral outcomes among
nursing neonates. Anesth Anal 85(3):600606, 1997.
9. Jakobi P, Solt I, Tamir A, Zimmer EZ: Over the counter
analgesic for post-cesarean pain. Am J OB Gyn 187(4):
REFERENCES 10661069, 2002.
1. Nikolajsen L, Sorensen HC, Jensent TS, et al: Chronic pain
following caesarean section. Acta Anaesthesiol Scand
48:111116, 2004.
SUGGESTED READING
2. Chen B, Kwan W, Lee C, et al: A national survey of obstet- Parker RK: Postoperative Analgesia: Systemic Techniques. In
ric post-anesthesia care in teaching hospitals (abstract). Chestnut DH (ed): Obstetric Anesthesia, Third edition.
Anesth Analg 76:543, 1993. Philadelphia, Elsevier Mosby, 2004, pp 461.
8
CHAPTER The High-Risk
Obstetric Patient
REGINA Y. FRAGNETO
79
80 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
patient must be considered when choosing which type parenteral medications, epidural analgesia provides
of central monitoring to utilize. superior pain relief. Many other advantages also exist.
Assessment of laboratory values is another important Uncontrolled labor pain will increase endogenous mater-
aspect of the preanesthetic evaluation. An elevated nal catecholamine levels. Because pre-eclamptic patients
hematocrit suggests hemoconcentration and hypov- exhibit an exaggerated response to vasopressors, these
olemia in a patient with pre-eclampsia. The most impor- increased levels of catecholamines can exacerbate
tant component of the complete blood count, however, hypertension. Epidural analgesia reduces maternal cate-
is the platelet count. Thrombocytopenia occurs in at cholamine levels and can help facilitate blood pressure
least 15% of women with pre-eclampsia, so it is essential control during labor. Pre-eclampsia compromises utero-
that a platelet count be obtained before proceeding with placental perfusion because of the diseases vasospastic
regional anesthesia. In patients with a platelet count effects, but Doppler studies have documented improved
<100,000/mm3, the risks of epidural hematoma must be intervillous blood flow when epidural analgesia is admin-
considered along with the benefits of epidural anesthesia istered for labor pain management in severe pre-eclamp-
when deciding whether to proceed with a neuraxial tic patients. This improved uteroplacental perfusion may
technique. Tests that evaluate platelet function might benefit the fetus during the stress of labor. Pre-eclamptic
assist the anesthesiologist in making this decision. patients are also at increased risk for emergency cesarean
Thromboelastography measures all phases of coagula- delivery compared to healthy parturients. Confirmation
tion, and the maximum amplitude of the trace is affected of a functioning epidural catheter placed early in labor to
by platelet function. Investigators have used this labora- provide analgesia will facilitate the use of epidural anes-
tory test to assess coagulation in pre-eclamptic patients thesia in such an emergency situation and avoid the risks
and suggest it may be useful for evaluating platelet func- associated with general anesthesia in pre-eclamptic
tion in patients with thrombocytopenia. The PFA-100 patients, including severe hypertension during laryn-
platelet function analyzer test measures global platelet goscopy and difficult intubation that may be exacerbated
function. This test gives reproducible results within min- by increased airway edema.
utes and is easy to perform. Initial studies in pre-eclamp- It is important to avoid hypotension associated with
tic patients found that platelet function remains normal epidural analgesia because this could worsen the status
in many patients with platelet counts between 70,000 of a fetus that may already be affected by the com-
and 100,000/mm3. This appears to support the practice promised uteroplacental perfusion that characterizes
of many obstetric anesthesiologists who do utilize neu- pre-eclampsia. Adequate intravenous hydration with
raxial anesthesia in pre-eclamptic patients with platelet crystalloid is necessary although it may be a challenge
counts within this range. The bleeding time is no longer to determine how much volume to administer. The
considered a reliable test to measure platelet function or majority of pre-eclamptic parturients are hypovolemic
risk of bleeding. and should receive at least 500 to 1000 mL of crystalloid
Routine measurement of prothrombin time (PT) and before administration of epidural local anesthetics.
activated partial thromboplastin time (PTT) is not neces- However, the volume of intravenous prehydration should
sary in most patients because disseminated intravascular be decreased in patients with signs of overhydration or
coagulation is rare in pre-eclampsia. In fact, it is highly pulmonary edema, and central hemodynamic monitor-
unlikely that PT or PTT will be prolonged in parturients ing may be needed to guide appropriate fluid manage-
with platelet counts >100,000/mm3. In patients with ment in these patients. The same local anesthetic
thrombocytopenia or abnormal liver function tests, it is drugs and doses used to initiate and maintain epidural
recommended to document normal PT and PTT before analgesia in healthy parturients can be used in pre-
proceeding with regional anesthesia. eclamptic parturients, but the block should be estab-
Blood urea nitrogen (BUN) and creatinine concentra- lished slowly and blood pressure monitored at intervals
tions should be measured to determine whether renal dys- of 1 to 3 minutes during drug administration to avoid
function is present. Liver function tests are also essential hypotension.
in the evaluation of pre-eclampsia. Finally, if the patient is If hypotension does occur, prompt treatment is
complaining of shortness of breath or has findings on needed. A drop in blood pressure that is 20% or greater
physical examination suggestive of pulmonary edema, an below the patients baseline requires treatment. An addi-
arterial blood gas and chest x-ray should be obtained. tional bolus of crystalloid should be infused, and admin-
istration of a vasopressor should be considered.
Labor Analgesia Although ephedrine has traditionally been the vasopres-
Adequate labor analgesia is an important component sor of choice to treat hypotension in obstetric anesthe-
in the care of pre-eclamptic women. Epidural analgesia is sia, a recent meta-analysis that compared ephedrine and
considered the preferred technique by many anesthesiol- phenylephrine for the treatment of hypotension found
ogists if contraindications dont exist. Compared to that umbilical artery pH was higher in neonates whose
The High-Risk Obstetric Patient 83
mothers received phenylephrine, suggesting the pre- in all parturients but also the risk of severe hypertension
ferred use of ephedrine is not supported by the available and associated cerebral hemorrhage.
data. However, all of the studies that have compared In patients with severe pre-eclampsia, it is advisable
ephedrine and phenylephrine included only healthy par- to avoid an epidural test dose containing epinephrine
turients. No data are available about the use of phenyle- because a significant rise in blood pressure could occur
phrine in pre-eclamptic women. Therefore, it remains if the epidural catheter were intravascular. Instead, a
logical to avoid a pure -agonist such as phenylephrine dose of plain local anesthetic can be administered and
in patients with pre-eclampsia, and ephedrine remains symptoms of intravascular injection elicited from the
the vasopressor of choice. Because patients with pre- patient. Once intravascular placement of the catheter
eclampsia do exhibit increased sensitivity to vasopres- has been ruled out, it is preferable to slowly administer
sors, the initial dose of ephedrine should not exceed 5 2% lidocaine with epinephrine 1:200,000 to achieve
mg to avoid a rebound hypertensive response. Further anesthesia adequate for surgery. This provides a dense
doses should be titrated to effect. block for surgery, and the amount of epinephrine that
Combined spinal-epidural (CSE) analgesia is another is absorbed systemically from the epidural space results
popular labor analgesia technique that provides rapid in a -adrenergic effect (e.g., vasodilation). Because one
and superior pain relief. The initial analgesia is produced advantage of epidural anesthesia is the ability to slowly
by an intrathecal opioid that does not produce a sympa- raise the anesthetic level, adding sodium bicarbonate to
thectomy, thus decreasing the risk of hypotension com- the local anesthetic solution should be avoided in the set-
pared to epidural analgesia. However, until the initial ting of nonurgent cesarean delivery. If epidural anesthe-
intrathecal analgesia has dissipated, the epidural catheter sia is being utilized for an urgent cesarean delivery with a
remains unproven. If emergency cesarean delivery were nonreassuring fetal heart rate pattern, 3% 2-chloroprocaine
required during this interval, the anesthesiologist could should be used to establish surgical anesthesia. The
be faced with a nonfunctioning catheter, thus necessitat- more rapid onset of this drug will expedite delivery,
ing the induction of general anesthesia. Therefore, while and its rapid maternal metabolism avoids the possible
CSE analgesia may be a reasonable technique to use in a ion trapping of local anesthesia in an acidotic fetus that
patient with mild pre-eclampsia and a reassuring fetal may occur with other agents, such as lidocaine and bupi-
heart rate tracing, some prefer epidural analgesia in vacaine.
patients with severe pre-eclampsia. The use of spinal anesthesia for cesarean delivery in
pre-eclamptic patients has previously been discouraged
Anesthesia for Cesarean Delivery because of concerns that marked hypotension may occur
Many factors must be considered when deciding on with the rapid onset of sympathectomy. However, some
the type of anesthesia to use for cesarean delivery. investigators have recently questioned the validity of this
Assessment of the mothers airway, coagulation, and clinical teaching. Many anesthesiologists now consider
hemodynamic status must occur. Any evidence of fetal spinal anesthesia a reasonable choice in patients with
compromise and the reason for and urgency of surgery mild pre-eclampsia although its use in patients with
must also be evaluated as the anesthesiologist develops a severe disease remains quite controversial.
plan for the anesthetic management of a pre-eclamptic While general anesthesia for cesarean delivery should
patient undergoing cesarean delivery. Epidural anesthe- be avoided in pre-eclamptic parturients whenever possi-
sia is the preferred anesthetic for nonurgent delivery ble, some clinical circumstances will require its use.
unless a severe coagulopathy is present. If an epidural Sustained fetal bradycardia, clinical signs of coagulopa-
catheter is already in place for labor, an attempt to utilize thy, obstetric hemorrhage secondary to placental abrup-
it for surgery should be made even in an emergent situa- tion, and patient refusal of regional anesthesia are
tion, unless the patient exhibits signs of hemodynamic situations that may require general anesthesia. Careful
instability. Various advantages are associated with the use evaluation of the patients airway is mandatory before
of epidural anesthesia for cesarean delivery. The anes- proceeding with induction of general anesthesia. If
thetic level required for surgery (T4T6) can be obtained examination suggests a high probability that intubation
slowly. This will decrease the likelihood of hypotension, will be difficult, awake fiber-optic intubation should
which might not be tolerated well by a fetus already be accomplished before inducing general anesthesia.
affected by the compromised uteroplacental perfusion of Otherwise, the increased risk of aspiration in pregnancy
pre-eclampsia. Compared to general anesthesia, it blunts requires that aspiration prophylaxis be administered pre-
the hemodynamic and neuroendocrine stress responses operatively and a rapid sequence induction with applica-
to surgery in patients with severe pre-eclampsia. Finally, it tion of cricoid pressure be utilized. All patients should
avoids the risks of general anesthesia that include not only receive sodium citrate, and if time allows, intravenous
the risks of aspiration and difficult intubation present metoclopramide and an H2-receptor antagonist should
84 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
The typical presentation for placenta previa is painless Anesthetic management of the patient undergoing
vaginal bleeding during the second or third trimester. cesarean delivery will depend on maternal and fetal sta-
The first bleeding episode usually stops spontaneously tus and the urgency with which surgery must proceed.
without causing hemodynamic or fetal compromise. The In parturients who have not experienced recent bleed-
diagnosis is determined by ultrasound examination. ing and are undergoing elective delivery, regional anes-
Whereas a double set-up vaginal examination was some- thesia is preferred for the same reasons it is preferred in
times required to confirm the diagnosis in the past, all pregnant women. Either epidural or spinal anesthesia
improved ultrasonographic technology has nearly elimi- is acceptable for elective cesarean delivery in the patient
nated the need to perform this high-risk procedure. with placenta previa. The type and dose of local anesthe-
sia should be chosen in the same manner as they are cho-
Anesthetic Management sen for any nonurgent cesarean delivery. These patients
Once the diagnosis of placenta previa has been estab- are at higher risk for intraoperative bleeding and
lished, the anesthesiologist must determine the obstetric cesarean hysterectomy than other parturients undergo-
management plan so care of the parturient can be coordi- ing elective cesarean delivery. Therefore, it is essential to
nated appropriately. Gestational age, maternal and fetal establish reliable large-bore intravenous access. The
condition, amount of bleeding, and type of placenta pre- anesthesiologist should also consider having cross-
via are all factors that will be considered when the obste- matched blood immediately available before proceeding
trician decides on the timing and mode of delivery. If the with surgery.
fetus is premature and bleeding has stopped, expectant If maternal hemorrhage or nonreassuring fetal status
management is usually chosen to allow time for fetal matu- necessitates emergency cesarean delivery in a parturient
ration. Throughout the patients hospitalization, intra- with placenta previa, general anesthesia is usually the anes-
venous access and a valid type and screen should be thetic technique of choice. Induction and maintenance of
maintained. Continuous availability of cross-matched blood anesthesia are similar to those described for emergency
is not necessary for most patients, however. When either delivery with abruptio placenta. After administration of a
fetal lung maturation has been achieved or the pregnancy nonparticulate antacid (Bicitra), rapid sequence induction
has reached 37 weeks gestation, delivery of the fetus will is performed. Ketamine and etomidate are the preferred
proceed. When a patient experiences ongoing hemor- induction agents in the setting of maternal hemorrhage
rhage, or there is evidence of maternal instability or nonre- because they are less likely than other induction drugs to
assuring fetal status, urgent cesarean delivery will be produce adverse hemodynamic effects in a hypovolemic
required regardless of gestational age. All parturients with patient. Unlike patients with abruptio placenta, there are
a total or partial placenta previa undergo cesarean delivery no concerns about the use of ketamine in these patients
because massive hemorrhage would occur with vaginal because there is no association between placenta previa
delivery. In some cases, the obstetrician will attempt a and uterine hypertonus. Succinylcholine is the muscle
vaginal delivery when a marginal placenta previa is pres- relaxant of choice during induction. Maintenance of gen-
ent. The use of epidural analgesia is recommended in this eral anesthesia will be determined by the hemodynamic
situation, and the anesthesiologist must be prepared for status of the mother, and generally consists of N2O and a
the possibility of hemorrhage and the need for an emer- volatile anesthetic before delivery with the addition of opi-
gent cesarean delivery. oids after delivery of the fetus.
88 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
The current sophistication of obstetric ultrasonography the uterine serosa and can also extend into other pelvic
available in the United States has nearly eliminated the structures, such as the bladder.
need for a double set-up cervical examination to confirm Over the past 50 years, the incidence of placenta acc-
the diagnosis of placenta previa. There may still be the reta has increased 10-fold. It is still a relatively rare obstet-
rare situation where this examination is required, how- ric complication, occurring in approximately one in
ever. The anesthesiologist must be prepared to handle every 2500 deliveries. Certain women, however, are at
massive hemorrhage as well as the need to proceed imme- significantly increased risk for developing placenta acc-
diately with cesarean delivery if the vaginal examination reta. Among parturients with placenta previa, an inci-
determines the presence of a placenta previa. Before the dence of 5% to 9% has been reported. The risk increases
obstetrician is allowed to perform the cervical examina- even further if a patient with placenta previa has a history
tion, all preparations necessary to proceed with emer- of previous cesarean delivery with the risk of accreta
gency cesarean delivery must be completed. Aspiration increasing as the number of previous cesarean deliveries
prophylaxis should be administered. Two large-bore intra- increases. The location of the placenta previa also affects
venous catheters should be inserted and maternal moni- risk. Among women with anterior or central placenta pre-
tors must be applied. Blood needs to be available in via who have had at least two cesarean deliveries, the risk
the operating room. All equipment and drugs for rapid- of developing placenta accreta is almost 40%.
sequence induction of general anesthesia must be ready Physicians should have a high index of suspicion for
and preoxygenation of the patient accomplished. placenta accreta when a parturient presents with pla-
centa previa and a history of previous cesarean delivery.
Both magnetic resonance imaging and ultrasound with
Placenta Accreta color flow mapping have successfully identified placenta
Placenta accreta is defined as a placenta that is abnor- accreta antenatally. However, the predictive value for
mally adherent to the myometrium. When the obstetri- both tests is poor. As a result, antenatal diagnosis is diffi-
cian attempts to remove the placenta after delivery, cult, and often the diagnosis is made at the time of sur-
massive hemorrhage ensues. Three types of abnormal gery, especially in patients without placenta previa.
placentation exist, with placenta accreta occurring most Placenta accreta requires obstetric hysterectomy in
frequently (Fig. 8-2). Placenta accreta describes a pla- the majority of cases. In fact, it is the most common indi-
centa that is adherent to the myometrium without invad- cation for obstetric hysterectomy in many hospitals. The
ing it. In placenta increta, the placenta actually invades blood loss with this surgical procedure is substantial. In
the myometrium. The most serious abnormal placenta- cases where separation of the placenta has been
tion, placenta percreta, invades all the way through to attempted before the diagnosis of accreta was made,
massive hemorrhage may have occurred even before hys-
terectomy is begun.
Anesthetic Management
Increta-17%
Normal When caring for the patient at risk for placenta accreta,
preoperative preparation and anticipation of potential
Decidua
problems by both the anesthesiologist and obstetrician
can significantly improve outcome for the patient. At least
two large-bore intravenous catheters should be inserted,
and the placement of arterial and central venous catheters
should be strongly considered. Packed red blood cells
should be immediately available in the operating room
before surgery begins, and discussion with the blood bank
should confirm that other blood products, including
Percreta-5% platelets and fresh frozen plasma, will be readily available
Accreta-78%
if needed. The use of cell saver technology should also be
considered after delivery has been accomplished. Because
arterial embolization has been reported to reduce the
intraoperative blood loss, preoperative consultation with
an interventional radiologist may be advisable. Finally, the
Figure 8-2 Anatomic relationship between placenta and obstetric operating rooms resources should be assessed
myometrium in abnormal placentations. (Redrawn from Benedetti
TJ: Obstetric hemorrhage. In Gabbe SG, Niebyl J, Simpson JL and a decision made as to whether the resources of the
[eds]: Obstetrics: Normal and Problem Pregnancies, Fourth general operating room suite could better serve the needs
edition. Philadelphia, Churchill Livingstone, 2002, p 519.) of a potentially complicated surgery.
The High-Risk Obstetric Patient 89
When placenta accreta is suspected, anesthesiologists and symptoms of rupture include sudden onset of
dont agree about the anesthetic of choice. Many anes- abdominal or suprapubic pain, vaginal bleeding, hemo-
thesiologists believe all these patients should receive dynamic instability, maternal tachycardia, uterine tender-
general anesthesia. The presence of a sympathectomy ness, recession of the presenting fetal part, and abrupt
from regional anesthesia could predispose the patient to change in uterine activity or pressure. Many of these
hypotension and inadequate perfusion of vital organs if signs and symptoms do not occur as frequently as many
massive hemorrhage occurs. If cesarean hysterectomy is clinicians assume (Fig. 8-3). It is important to differenti-
necessary, patient discomfort caused by the additional ate between uterine scar dehiscence and uterine rup-
surgical manipulation might require conversion to gen- ture. Dehiscence, which is more common than frank
eral anesthesia. Intubation could also become necessary rupture, is a separation of a previous uterine incision
if blood loss results in patient instability. Because of these that is often asymptomatic and does not result in mater-
potential situations, many anesthesiologists prefer to nal hemorrhage or fetal distress. Frequently, a dehis-
induce general anesthesia in a controlled situation at the cence is found incidentally and does not require
beginning of surgery rather than during a time of crisis. additional treatment. Patients with a low transverse scar
Other anesthesiologists argue, however, that regional are more likely to experience dehiscence than rupture.
anesthesia will provide adequate anesthesia for obstetric In contrast, uterine rupture is a uterine wall defect that
hysterectomy in many patients. If all patients at risk for results in maternal hemorrhage or fetal distress.
placenta accreta were required to undergo general anes- Sometimes the uterine contents (fetus and placenta)
thesia, many women would unnecessarily face the have extruded into the abdominal cavity. This can be a
increased risks of general anesthesia associated with life-threatening situation for the mother or fetus and
pregnancy. In addition, they would not have the oppor- requires emergency cesarean delivery or postpartum
tunity to be awake for the birth of their infants. In laparotomy as well as uterine repair or hysterectomy.
patients in whom there is concern that intubation could Anesthetic management of a uterine rupture re-
be difficult, it is prudent to utilize general anesthesia so quires the anesthesiologist to simultaneously provide
that intubation can be performed in a controlled, nonur- aggressive fluid resuscitation and anesthesia for emer-
gent setting. In some patients at risk for placenta accreta, gency cesarean delivery or postpartum laparotomy. If
however, it is probably reasonable to offer regional anes- the parturient already has an epidural catheter in place
thesia. If regional anesthesia is chosen, epidural anesthe- for labor analgesia, it is acceptable to use epidural
sia is recommended over spinal anesthesia because the anesthesia for delivery and uterine repair, provided
duration of surgery could be prolonged. the patient is hemodynamically stable. The emergent
BP
60
ABNORMAL PRESENTATION
When VBAC was initially introduced, some obstetri-
cians withheld epidural analgesia from these patients Many types of abnormal presentation exist, includ-
because of a concern that abdominal pain associated ing breech, transverse lie, face, brow, and compound pre-
with uterine rupture would be masked by the analgesia, sentations. Pregnancies complicated by an abnormal
and diagnosis would be delayed. However, experience in presentation are associated with an increased incidence of
the management of women attempting a trial of labor has obstetric complications. Optimal management of these
not borne out this concern. First, abdominal pain is not a patients requires coordination and cooperation among the
reliable sign of uterine rupture. Second, when the dilute obstetric care team, including obstetrician, anesthesiolo-
local anesthetic + opioid solutions that are commonly gist, obstetric nurse, and pediatrician. Breech presentation
utilized in current obstetric anesthesia practice are is the most common malpresentation and occurs in 3%
administered, it has been found that pain associated with to 4% of term pregnancies. Among preterm fetuses, the
uterine rupture is not obscured. In fact, when a woman incidence of breech presentation may be as high as
who has been receiving adequate epidural labor analge- 40% although the vast majority of these fetuses assume
sia experiences a sudden loss of analgesia, this should be a vertex presentation by 34 weeks gestation. Three types
a warning that uterine rupture may be occurring, and of breech presentation exist (Fig. 8-4): frank breech, in
the obstetrician should be alerted. which the hips are flexed and the knees are extended;
Obstetricians and anesthesiologists now believe that incomplete (footling) breech, in which one or both of the
epidural analgesia is an ideal technique of pain relief lower extremities are extended at the hip; and complete
for parturients attempting a VBAC. Many studies have breech, in which both the hips and knees are flexed. Frank
reported the successful use of epidural analgesia in these breech occurs most commonly. Vaginal breech delivery is
patients. Some women are more likely to choose a trial of only considered with a frank breech presentation.
labor rather than elective repeat cesarean delivery if they In the United States, there has been an increasing trend
know the superior pain relief provided by epidural anal- to deliver singleton breech fetuses via cesarean delivery.
gesia is available to them. Because 60% to 80% of patients Obstetricians have chosen this route of delivery because
undergoing a trial of labor have a vaginal delivery, a several retrospective studies as well as meta-analyses have
significant number of VBAC patients will ultimately reported increased perinatal morbidity and mortality with
require a cesarean delivery. Epidural analgesia can quickly vaginal breech delivery. However, other studies have not
be converted to surgical anesthesia in these patients. The found poorer neonatal outcome with vaginal delivery.
dosing strategy used to provide labor analgesia to Mode of delivery with breech presentation remained con-
patients attempting VBAC should not differ from that uti- troversial throughout the 1990s. The first large, interna-
lized in the general obstetric population. Attention tional, multicenter randomized clinical trial that evaluated
should be paid to using the smallest doses and concentra- the effect of mode of delivery on both neonatal and mater-
tions of drugs that provide satisfactory analgesia. Large nal outcome was published in 2000. It found that neonatal
doses and concentrations that could produce surgical mortality and serious morbidity were significantly greater
anesthesia rather than analgesia should be avoided because with vaginal breech delivery compared to cesarean deliv-
a dense block might mask abdominal pain associated ery. In addition, cesarean delivery was not associated with
with uterine rupture. increased maternal morbidity. As a consequence of these
CSE analgesia is another popular technique for provid- study data, ACOG revised its Committee Opinion on mode
ing pain relief during labor. Like epidural analgesia, of term singleton breech delivery in 2001. They now rec-
the pain relief provided by intrathecal opioids and small ommend that a singleton breech fetus be delivered via
92 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
planned cesarean delivery. They also state that if a vaginal sider epidural analgesia to be an ideal anesthetic tech-
breech delivery is pursued, great caution should be exer- nique for labor and vaginal breech delivery. The advan-
cised. ACOG does clarify that this recommendation for tages of this technique include superior labor analgesia,
planned cesarean delivery does not apply to parturients inhibition of early pushing before the cervix has become
who present in advanced labor in whom delivery is immi- fully dilated, provision of a relaxed pelvic wall and per-
nent nor in twin gestations where the second twin is in ineum at delivery, and the ability to extend the block if
the breech presentation. an emergency cesarean delivery becomes necessary.
Because of the risk of serious obstetric complications, it
is advisable to initiate epidural analgesia early in labor.
Anesthetic Management of Breech Vaginal It can be challenging to effectively meet all the anes-
Delivery thetic goals for providing epidural analgesia to a parturi-
The recent ACOG Committee Opinion has relegated ent attempting vaginal breech delivery. During the first
the breech vaginal delivery to a relatively rare procedure. stage of labor, the epidural block must be dense enough
However, because serious complications may occur to prevent early pushing. However, once the second
during a vaginal breech delivery, it is imperative that stage of labor is reached, the epidural block must not
anesthesia coverage be readily available and the anesth- inhibit the patients ability to push effectively because it
esiologist have a sound understanding of the anes- is essential that the infant deliver spontaneously to the
thetic implications associated with this procedure. umbilicus. The anesthesiologist must also be able to
Umbilical cord prolapse and fetal head entrapment are quickly provide dense perineal anesthesia if the obstetri-
the two most serious complications associated with cian decides to assist delivery with forceps. Continuous
breech vaginal delivery. Both are true obstetric emergen- epidural infusion or epidural PCA using a solution of
cies, and the anesthesiologist must be prepared to dilute local anesthetic that minimizes motor block (e.g.,
respond to them emergently. bupivacaine or ropivacaine) plus a lipid-soluble opioid
There are three types of breech vaginal delivery: spon- (e.g., fentanyl or sufentanil) is usually effective for labor
taneous breech delivery in which no traction is applied; and delivery. The administration of 3% 2-chloroprocaine
assisted breech delivery in which the obstetrician assists quickly achieves dense perineal anesthesia if forceps
delivery of the chest and head with forceps after the need to be applied.
neonate spontaneously delivers to the umbilicus; and Umbilical cord prolapse is the most common serious
total breech extraction in which traction is applied obstetric complication associated with vaginal breech
on the feet and ankles to deliver the entire body. Total delivery. It can occur at any time during labor and
breech extraction is rarely performed in current obstet- requires emergency cesarean delivery. It often results
ric practice and is only used to deliver a second twin. in profound fetal bradycardia. Once the problem is
In the past, some obstetricians have not supported identified, a member of the obstetric team must elevate
the use of epidural analgesia for patients undergoing the fetal head off the umbilical cord until delivery is
vaginal breech delivery because they were concerned accomplished to prevent prolonged umbilical cord
that it would decrease the womans expulsive efforts. compression. If an epidural catheter is in place, the anes-
Currently, most obstetricians and anesthesiologists con- thesiologist should quickly extend anesthesia with 3%
The High-Risk Obstetric Patient 93
2-chloroprocaine. However, the anesthesiologist should the time of fetal head entrapment, general anesthesia will
also be prepared to induce general anesthesia in case almost certainly be required to provide the skeletal mus-
adequate surgical anesthesia is not present when the cle and cervical relaxation as well as the effective analge-
obstetrician is ready to begin surgery. If epidural analge- sia necessary to successfully deliver the entrapped fetal
sia is not already established, general anesthesia is nearly head.
always required due to the time factor and the inability to As previously discussed, most women presenting with
position the patient for regional anesthesia placement a fetus in the breech presentation will undergo elective
while the fetal head is being elevated. cesarean delivery. Regional anesthesia is the technique of
Entrapment of the fetal head, although rare, is proba- choice unless contraindications exist. Even with an
bly the most feared complication of vaginal breech deliv- abdominal delivery, uterine relaxation may be required to
ery. Most of these cases occur in preterm fetuses less facilitate delivery of the breech infant. Nitroglycerin
than 32 weeks gestation. If the fetal head becomes should be immediately available. The neonate delivered in
entrapped after delivery of the body, the obstetrician the breech presentation is more likely to be depressed at
must choose among three management options to delivery. Therefore, it is essential that personnel trained in
deliver the infant. These include: emergency cesarean neonatal resuscitation be available at all breech deliveries,
delivery after the fetuss body has been returned to the both vaginal and abdominal.
uterus; performance of Dhrssen incisions in the cervix,
which can result in significant bleeding; or provision of
skeletal and cervical/uterine smooth muscle relaxation. Anesthetic Considerations in External
Both of the latter maneuvers are used to facilitate vaginal Cephalic Version
delivery of the entrapped fetus. External cephalic version is used to convert a breech
The obstetrician may request that the anesthesiologist or transverse lie presentation to a vertex presentation,
provide skeletal and cervical/uterine smooth muscle thus allowing vaginal delivery. During the procedure,
relaxation to assist delivery of the head. If an epidural the obstetrician applies manual pressure to the womans
catheter is in place, skeletal muscle relaxation can abdomen in an attempt to change the position of the
quickly be achieved with the administration of 3% 2- fetus. If version to the vertex presentation is success-
chloroprocaine. Although epidural anesthesia will not pro- ful, vaginal delivery is accomplished at essentially the
vide cervical relaxation, the provision of a relaxed pelvic same rate as the general obstetric population. External
wall and perineum as well as effective pain relief will facili- cephalic version is usually performed after 36 weeks ges-
tate delivery of the aftercoming head. For successful deliv- tation before the patient is in active labor. Early labor
ery of an entrapped head, cervical relaxation is required. does not preclude successful version, but the procedure
Nitroglycerin is a potent smooth muscle relaxant that has is generally not successful once the presenting part has
successfully provided uterine relaxation for a variety of entered the pelvis. Success rates ranging from 50% to
clinical scenarios. While the uterus is comprised prima- 80% have been reported for the procedure, with an aver-
rily of smooth muscle, only 15% of the cervix is smooth age rate of approximately 60%. Risks of external cephalic
muscle. Therefore, some physicians have suggested that version include placental abruption and umbilical cord
nitroglycerin will not effectively provide the necessary compression, which could result in acute fetal distress
cervical relaxation to deliver an entrapped fetal head. requiring emergency cesarean delivery.
However, two case reports have suggested that adminis- Because vaginal breech delivery is no longer recom-
tration of intravenous nitroglycerin was primarily respon- mended by ACOG, anesthesiologists are likely to see an
sible for facilitating delivery of the entrapped head of a increase in external cephalic version procedures in an
premature fetus. In these cases, 150 and 600 g of nitro- attempt to decrease cesarean delivery rates due to abnor-
glycerin were administered. In other obstetric situations, mal presentation. Certain maneuvers may increase the
such as retained placenta, doses as low as 50 to 100 g success rate for external cephalic version. Uterine tocoly-
of intravenous nitroglycerin have provided uterine sis is frequently administered to facilitate the procedure.
relaxation. Because rapid sequence induction of general Subcutaneous terbutaline 0.25 mg is usually administered
anesthesia and administration of a high concentration 15 to 20 minutes before the procedure is performed.
(2 to 3 MAC) of a volatile halogenated agent is the only Some obstetricians will also administer nitroglycerin
other technique the anesthesiologist can offer to provide during the version. An anesthesiologist should be available
cervical/uterine relaxation, it seems reasonable to first whenever an external cephalic version is being attempted
administer nitroglycerin when fetal head entrapment in case emergency delivery is required. The obstetrician
occurs, followed by general anesthesia if adequate relax- and anesthesiologist must also decide whether neuraxial
ation is not achieved with nitroglycerin. If epidural anal- anesthesia should be administered for external cephalic
gesia has not already been established in the parturient at version.
94 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
in cardiac output is greater in these patients. The most examination because presentation of the second twin
significant cardiovascular change, however, is due to the can change after delivery of the first twin. Fetal heart
increased uterine size and weight in multiple gestation. tones must be evaluated because fetal bradycardia can
As a result, aortocaval compression and the supine also develop after delivery of Twin A. If Twin B is in the
hypotensive syndrome are likely to be more severe. vertex presentation and the fetal heart rate pattern is
Pregnancy effects on the central nervous system also reassuring, the obstetrician will generally proceed with
appear to be exaggerated in multiple gestation, and their vaginal delivery. If Twin B has a nonvertex presentation,
significance is of special importance to the anesthesiolo- the obstetricians management options include: external
gist. The spread of spinal anesthesia has been noted to be cephalic version followed by vaginal delivery of a vertex
greater in women with twin gestations compared to sin- infant; internal podalic version with total breech extrac-
gleton gestations. Again, increased uterine size resulting tion; or cesarean delivery. Delivery of the nonvertex sec-
in greater aortocaval compression may contribute to the ond twin is the one situation in which performance of
greater spread. In addition, the higher maternal serum an internal podalic version and total breech extraction
progesterone levels that are present in patients with mul- is still considered appropriate obstetric practice.
tiple gestation may contribute to the greater spread of Communication between the obstetrician and anesthesi-
spinal anesthesia because progesterone is known to ologist regarding the planned delivery method for Twin
increase nerve sensitivity to local anesthetics. B is essential so that appropriate anesthesia and uterine
relaxation can be provided, if necessary.
Obstetric Management
In planning the obstetric management for a patient Anesthetic Management
with multiple gestation, the route of delivery must first Labor and Vaginal Delivery
be decided. Cesarean delivery is nearly always chosen Epidural analgesia is usually considered the method of
for the delivery of triplets and higher order multiple choice for labor and planned vaginal delivery of a twin ges-
births. For twin gestations, the presentations of Twin A tation. It provides effective pain relief, optimal delivery
and Twin B are considered when deciding on the mode conditions, and the route for a rapid induction of anesthe-
of delivery. When Twin A is breech, ACOG recommends sia should an emergency cesarean delivery be required for
cesarean delivery because the safety of vaginal birth has Twin B. Epidural drug administration is similar to that used
not been documented, and the possibility of locked for other laboring parturients. It is essential that the anes-
twins exists if Twin B is vertex. Although locked twins thesiologist establish that the epidural catheter is function-
rarely occur, fetal mortality is high with this complica- ing well because these patients are at increased risk for
tion. If both twins are vertex, vaginal delivery is gener- cesarean delivery. Parturients with twin gestation are also
ally recommended unless other contraindications to more prone to supine hypotensive syndrome. Therefore,
vaginal birth exist. The route of delivery for vertex/non- particular attention must be paid to maintaining left uter-
vertex twins, however, is more controversial. Because ine displacement, and aggressive treatment with intra-
ACOG currently recommends planned cesarean delivery venous fluids and ephedrine should be instituted if
for singleton fetuses in the breech presentation, some hypotension does develop. Because the incidence of post-
obstetricians now advocate cesarean delivery when partum hemorrhage is increased with multiple gestation,
Twin B is breech. However, the ACOG recommendation large-bore venous access should be established early in
specifically states that this opinion does not apply to a labor, and a current type and screen specimen must be
second twin in the nonvertex presentation. If the esti- present in the hospitals blood bank. CSE analgesia is less
mated fetal weight of Twin B is between 1500 and 4000 desirable than conventional epidural analgesia in laboring
g, it is considered reasonable to attempt vaginal delivery parturients with a twin gestation because the epidural
of both twins because most studies have not shown catheter remains unproven during the initial period of
improved neonatal outcome of Twin B with cesarean intrathecal analgesia.
delivery. Regardless of these recommendations, it does During vaginal delivery of a twin gestation, some of the
appear that the incidence of combined vaginal-cesarean anesthetic concerns are similar to those discussed for vagi-
and elective cesarean deliveries for twin gestations is nal breech delivery. After Twin A has been delivered,
increasing at some hospitals. there is an increased risk of prolapse of the umbilical
When vaginal delivery of a twin gestation is planned, cord in Twin B that would necessitate emergency cesarean
the delivery should occur in an operating room where delivery. If a breech delivery of the second twin is
emergency cesarean delivery can be accomplished. attempted, the anesthesiologist must be prepared to
Once Twin A is delivered vaginally, the obstetrician must respond to an entrapped fetal head.
then decide how to proceed with delivery of Twin B. Because of a significant likelihood that some form
First, presentation must be confirmed by ultrasound of manipulation will be required for delivery of Twin B,
96 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
Women who are unable to increase insulin production An increased incidence of intrauterine fetal death has
sufficiently to compensate for this resistance develop been associated with diabetes. Reduced uteroplacental
gestational diabetes. These patients are at increased risk perfusion is felt to be a significant contributing factor.
for Type 2 diabetes mellitus later in life. In parturients However, aggressive antenatal fetal surveillance in dia-
with pre-existing diabetes, the insulin resistance of preg- betic parturients has been successful in substantially
nancy leads to a progressive increase in insulin require- decreasing the number of intrauterine fetal deaths
ments. Despite these increased insulin requirements, among diabetic women. Fetal macrosomia is another
patients with Type 1 diabetes are at significant risk complication of both gestational and pregestational dia-
for developing hypoglycemia, especially during early betes. This certainly contributes to the increased inci-
pregnancy. dence of cesarean delivery. In addition, during vaginal
Diabetic ketoacidosis (DKA) is another concern in delivery the risk of shoulder dystocia and birth trauma is
parturients with Type 1 disease. The pregnant state of increased for the macrosomic fetus.
relative insulin resistance is associated with enhanced After delivery, neonates of diabetic mothers face other
lipolysis and ketogenesis. Therefore, DKA can occur at complications. Neonatal hypoglycemia is the most com-
significantly lower glucose levels than is typically associ- mon problem encountered, occurring in 5% to 12% of
ated with DKA in nonpregnant patients. DKA can be these infants. This is a 6- to 16-fold increase compared to
diagnosed in parturients with glucose levels as low as infants of nondiabetic mothers. The fetal hyperinsuline-
200 to 250 mg/dL. It most commonly occurs in the sec- mia that develops in response to maternal hyperglycemia
ond and third trimesters. The administration of -adren- is believed to be the cause of neonatal hypoglycemia.
ergic drugs for tocolysis and glucocorticoids for fetal Although recent data do not support diabetes as an inde-
lung maturation may precipitate DKA. Infection is pendent risk factor for infant respiratory distress syndrome
another risk factor for DKA, and infection rates in preg- (RDS), a variety of factors may increase the incidence
nant patients with Type 1 diabetes are higher than rates of RDS among the neonates of diabetic parturients, espe-
in nondiabetic parturients. The presence of DKA has cially in those infants whose mothers had poor glycemic
also been associated with nonreassuring fetal heart rate control during pregnancy. Obviously, it is important that
patterns. However, these patterns usually resolve once personnel skilled in the care of neonates be readily avail-
the maternal metabolic abnormalities have been cor- able during the delivery of a diabetic woman.
rected, so every effort is made to avoid fetal intervention
and preterm delivery unless the heart rate abnormalities
persist after treatment of the DKA. Obstetric Management
Several complications, both maternal and fetal, occur Optimal glycemic control is a major focus in the
more frequently in diabetic pregnancies. The incidence obstetric care of diabetic parturients because it may min-
of pre-eclampsia is increased in diabetic patients, both imize several complications, including macrosomia,
gestational and pregestational. Polyhydramnios is also birth injury, fetal lung immaturity, and perinatal death. In
more common. Diabetic parturients are more likely to patients with pre-existing disease, this management
require cesarean delivery. Uteroplacental perfusion is should actually begin in the preconception period
decreased 35% to 45% in diabetic patients compared to because strict glycemic control before conception is
nondiabetic patients. This decreased blood flow occurs associated with a decrease in congenital anomalies. Self-
even in women with well-controlled gestational diabetes. monitoring of fingerstick blood glucose measurements
An increased incidence of abnormal fetal heart rate pat- is performed several times each day throughout preg-
terns is associated with the reduction in uteroplacental nancy. Tight control with a blood glucose concentration
perfusion. of 60 to 120 mg/dL is desired. Frequent changes in
The fetal effects of maternal diabetes are numerous. insulin therapy are usually required to maintain adequate
In women with pre-existing diabetes, the risk of congeni- glycemic control, with insulin requirements generally
tal anomalies is increased and is now the leading cause of increasing progressively throughout pregnancy. The
perinatal mortality in diabetic pregnancies. The inci- treatment regimen may require three to four daily insu-
dence of major malformations is 8.5% to 10% in large lin injections or use of a continuous subcutaneous
studies, which is a two- to six-fold increase compared to insulin pump. Strict glycemic control is also necessary
nondiabetic patients. Cardiovascular and central nervous during labor and delivery to decrease the risk of neonatal
system malformations are the most common. While the hypoglycemia. The recommended strategy for glucose
etiology of these fetal anomalies is likely multifactorial, control during labor is summarized in Box 8-7.
the most important factor appears to be poor glucose Insulin requirements decrease significantly in the
control during the period of organogenesis. Initiation of postpartum period, and glycemic control does not need
strict glycemic control during the preconception period to be as tight as during labor and delivery. If an insulin
has been found to decrease the incidence of congenital infusion is utilized during labor, it should be discontin-
anomalies. ued after delivery to avoid maternal hypoglycemia.
98 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
be taken preoperatively and intraoperatively. If hypoten- be at risk for pulmonary hypertension, which is associ-
sion does occur, prompt, aggressive therapy is necessary. ated with a high maternal mortality rate. The gastroin-
Finally, if a patient with longstanding, pre-existing dia- testinal changes associated with obesity are similar to the
betes has a positive prayer sign, the anesthesiologist changes that occur in all parturients. Over 80% of non-
should carefully assess the risk for difficult intubation and pregnant obese patients have a gastric pH <2.5 and a
decide if awake intubation is warranted. gastric volume >25 mL, thus placing these patients at
risk for aspiration. It is unclear whether morbid obesity
in pregnancy further decreases gastric pH and increases
MORBID OBESITY gastric volume compared to nonobese parturients.
Especially in obese patients, utilization of the sitting the epidural catheter remains unproven. If emergency
rather than the lateral position will often facilitate suc- cesarean delivery was required during this time interval
cessful identification of the epidural space. and epidural anesthesia failed, general anesthesia would
Because the failure rate for epidural analgesia is be required. Therefore, because the risks of general anes-
increased in obese parturients, it is essential that the thesia are significant in morbidly obese parturients and
anesthesiologist frequently monitor these patients and the incidence of cesarean delivery is increased in these
promptly replace the epidural catheter if evidence sug- patients, I do not advocate using CSE analgesia for admin-
gests inadequate analgesia. Adopting a particular proce- istering labor analgesia in this patient population.
dure to secure the epidural catheter may also decrease
epidural failure rates due to catheter displacement. Anesthesia for Cesarean Delivery
Epidural analgesia should be initiated early in labor to The incidence of cesarean delivery is increased in
minimize the chance that general anesthesia would be obese women compared to nonobese women. In one
required should emergency cesarean delivery become study, nearly 50% of morbidly obese parturients who
necessary at any time during labor. The goal of epidural underwent a trial of labor eventually required cesarean
analgesia for all parturients is to provide excellent analge- delivery. The anesthesiologist may confront several chal-
sia while minimizing motor block. This is especially lenges when caring for these patients. Longer surgery
important in morbidly obese parturients because nursing duration and increased blood loss should be anticipated.
care is very difficult if the patient cannot move Particular attention should be paid to positioning of the
adequately during labor and delivery. Therefore, admin- patient. Left uterine displacement is mandatory, but the
istration of a dilute local anesthetic + opioid is recom- anesthesiologist must be certain that the patient is ade-
mended. Bupivacaine or ropivacaine 0.125% to 0.0625% quately secured to the operating table before tilting the
+ fentanyl 2 g/mL will achieve adequate analgesia with table. The obstetrician frequently requests cephalad retrac-
minimal motor block in most parturients. tion of the patients panniculus so that a Pfannenstiel skin
Continuous spinal analgesia is another option for labor incision can be utilized. If cephalad retraction is per-
analgesia which does provide some advantages over formed, the anesthesiologist must be vigilant for hypoten-
epidural analgesia in morbidly obese patients. Superior sion caused by aortocaval compression that could lead to
labor analgesia can be achieved using intermittent doses fetal or maternal compromise as well as signs or symp-
of intrathecal opioids during early labor and opioids plus toms of maternal respiratory compromise caused by
small doses of local anesthetics during the late stage of increased chest wall compliance. The obstetrician must
labor and delivery. Because analgesia can be provided be aware that if the patient experiences adverse effects
with minimal doses of local anesthetics compared to from the cephalad retraction of the panniculus, this
epidural analgesia, motor block is often nonexistent. This approach will need to be abandoned, and a vertical skin
might facilitate vaginal delivery and will certainly make incision may be required. Because these patients are at
nursing care easier. More importantly, correct placement high risk for aspiration, all patients should receive aspira-
of the catheter is confirmed by aspiration of cerebrospinal tion prophylaxis preoperatively, even if general anesthesia
fluid, so initial failure rates should be less than with is not initially planned. Sodium citrate, metoclopramide,
epidural analgesia. If the catheter becomes dislodged dur- and an H2-receptor antagonist are all recommended.
ing labor, identification of the problem and replacement Finally, regardless of the type of anesthesia chosen, the
of the catheter could occur more promptly compared to anesthesiologist should realize that technical difficulties
epidural analgesia because the loss of ability to aspirate are more likely to occur in the morbidly obese parturient.
cerebrospinal fluid would confirm the dislodgement The risks associated with general anesthesia in
before analgesia had dissipated. Identification of a dis- pregnant patients (e.g., difficult airway, aspiration) are
placed epidural catheter is generally delayed until the increased even further in obese parturients. Therefore,
patient no longer has adequate pain relief. Because spinal regional anesthesia is preferred for cesarean delivery.
microcatheters are not currently available for clinical use, Epidural anesthesia offers several advantages. The dose
a large-gauge epidural needle and catheter must be used to of local anesthetic can slowly be titrated. This is espe-
administer continuous spinal analgesia. Therefore, the risk cially important in obese patients because studies sug-
of developing a postdural puncture headache is a signifi- gest that the epidural spread of local anesthetic is
cant disadvantage of this technique. There have been exaggerated in these patients, leading to higher sensory
some anecdotal reports that the incidence of spinal levels than might be expected. Slow administration
headache is decreased in morbidly obese patients, but this of epidural local anesthetic also results in a slower onset of
has not been proven, and certainly some patients will sympathetic blockade, which could decrease the risk
develop a headache and require treatment. of hypotension. An important advantage of epidural
CSE analgesia provides excellent pain relief for labor. anesthesia is the ability to administer additional local
However, until the initial intrathecal analgesia dissipates, anesthetic to maintain surgical anesthesia if surgery is
The High-Risk Obstetric Patient 103
prolonged. Rarely do these patients experience respira- if the dose is reduced to avoid a high sensory level, the
tory difficulty associated with the high level of sensory anesthetic block could be inadequate for surgery. Most
blockade (T4T6) required for surgery. The choice of important, surgery duration is more likely to be pro-
local anesthetic drug will be determined by the urgency longed in morbidly obese patients. If surgery duration
of surgery and the personal preference of the physician. extends beyond the duration of spinal anesthesia, induc-
Some physicians prefer to use 2% lidocaine with epi- tion of general anesthesia would be required, thus expos-
nephrine 1:200,000 for nonemergent situations and 3% ing the patient to all the risks associated with that
2-chloroprocaine for emergency cesarean deliveries. anesthetic technique.
Some disadvantages of epidural anesthesia do exist. CSE anesthesia is another option for cesarean delivery.
Compared to spinal anesthesia, the depth of sensory With this technique, the onset of blockade is achieved
blockade may be less, and the patient may experience more quickly and the sensory block is denser than with
discomfort during the surgery. In the morbidly obese epidural anesthesia. However, significant disadvantages
parturient, the greatest disadvantage of this technique is exist. The dose of spinal anesthesia cannot be titrated. In
the high initial failure rate. However, because the bene- addition, the epidural catheter remains untested. If the
fits of regional anesthesia for cesarean delivery are so duration of surgery outlasts the duration of spinal anes-
great in morbidly obese patients, an initial failure should thesia and epidural anesthesia must be administered, the
not deter the anesthesiologist from making subsequent possibility exists that the epidural catheter will not func-
attempts to perform epidural anesthesia. tion appropriately, thus necessitating general anesthesia.
Some of the disadvantages of epidural anesthesia can Because technical difficulties with regional anesthesia
be avoided with continuous spinal anesthesia while main- are more frequently encountered in morbidly obese
taining many of the advantages of an epidural technique. patients, the likelihood of a nonfunctioning epidural
Therefore, some anesthesiologists consider it the ideal catheter may be increased. Therefore, some physicians
anesthetic for cesarean delivery in morbidly obese do not consider CSE anesthesia a preferred technique for
patients. Like epidural anesthesia, this technique allows cesarean delivery in morbidly obese women.
for slow titration of the local anesthetic dose. Because Although general anesthesia for cesarean delivery is
some studies suggest that obesity results in an exaggerated avoided whenever possible in morbidly obese patients,
spread of spinal local anesthetic, thereby increasing the some clinical scenarios will require its use. Induction of
risk of high spinal anesthesia, the ability to titrate the dose general anesthesia in a morbidly obese parturient is
of local anesthetic is an important benefit in morbidly fraught with danger and requires meticulous planning
obese parturients. Administration of incremental 0.5-mL and preparation to avoid disaster. Anesthesia-related mor-
doses of 0.75% hyperbaric spinal bupivacaine should be tality during cesarean delivery is increased in obese
continued until a T4T6 sensory level is achieved. Spinal patients, and many of these deaths are due to aspiration
anesthesia generally produces a denser sensory block and airway complications during general anesthesia.
compared to epidural anesthesia, and patients undergoing Careful evaluation of the airway is essential, even in
cesarean delivery with spinal anesthesia often seem to emergency situations. Intubation is known to be more
experience less intraoperative discomfort than patients difficult in obstetric patients; the very large breasts and
receiving epidural anesthesia. Most important, the initial fat deposits in the neck and shoulders often present
failure rate of the continuous spinal technique should be in obese patients increase the difficulty even further.
significantly less than epidural anesthesia because the aspi- These anatomic characteristics also make mask ventila-
ration of cerebrospinal fluid through the spinal catheter tion more difficult in the morbidly obese patient.
confirms correct placement. Obviously, the major disad- Previous easy intubation does not guarantee success
vantage of this technique is the high likelihood that the in the pregnant patient. In one study, difficult intuba-
patient will develop a spinal headache. tion was encountered in 33% of morbidly obese parturi-
Single-shot spinal anesthesia is the quickest regional ents. In two thirds of those patients, difficulty was not
anesthesia technique available for cesarean delivery. anticipated.
When the urgency of the situation does not allow time to Before proceeding with the induction of general anes-
perform a continuous neuraxial technique, the adminis- thesia, the anesthesiologist must be certain that any air-
tration of spinal anesthesia to a morbidly obese parturi- way equipment that might be necessary is immediately
ent may be preferred over general anesthesia. However, available. A variety of laryngoscope blades, small endo-
significant disadvantages of single-shot spinal anesthesia tracheal tubes, a fiber-optic bronchoscope, and a short-
in the morbidly obese patient do exist. The dose of local handled laryngoscope, which makes insertion of the
anesthetic cannot be titrated, and exaggerated spread of laryngoscope easier in patients with large breasts, should
the local anesthetic could lead to high spinal anesthesia all be available. A laryngeal mask airway and equip-
with the use of a conventional spinal dose. However, the ment for performing percutaneous cricothyrotomy and
spread of local anesthetic cannot be easily predicted, so transtracheal jet ventilation should also be available in
104 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
the event that both intubation and mask ventilation can- may be decreased to avoid any effects on uterine tone.
not be successfully performed. Although use of a laryn- Some morbidly obese patients may require a high con-
geal mask airway will not protect against aspiration, centration of oxygen to maintain adequate oxygenation
it provides the ability to ventilate the patient as well in the supine position. In that case, nitrous oxide might
as a conduit for performing fiber-optic intubation. The need to be eliminated or the concentration reduced.
anesthesiologist should be aware that technical diffi- Other maneuvers that can be utilized intraoperatively to
culties may be encountered when attempting to per- improve oxygenation include the use of a large tidal vol-
form percutaneous cricothyrotomy in a morbidly obese ume and the administration of positive end-expiratory
patient. Regardless of the urgency of the situation, rapid pressure, although some controversy exists concerning
sequence induction of general anesthesia should not pro- the utility of the latter in obese patients. At the end of
ceed if difficult intubation is anticipated. Instead, awake surgery, the morbidly obese parturient should be fully
intubation, usually utilizing fiber-optic laryngoscopy, awake before removing the endotracheal tube in order to
should be performed. Although it may be difficult for the decrease the risk of aspiration.
anesthesiologist to insist on this plan when the obstetri-
cian is emphasizing the dire condition of a fetus, the
anesthesiologist must realize that neither mother nor CARDIAC DISEASE
fetus will benefit from a situation in which neither intu-
bation or ventilation can be achieved in an apneic Cardiac disease complicates up to 4% of pregnancies.
patient. Depending on the type and severity of the disorder, mater-
Once the decision has been made to proceed with nal and fetal outcome may be adversely affected. Over the
rapid sequence induction of general anesthesia, the anes- past several years, advances in medical and surgical treat-
thesiologist should make certain that aspiration pro- ment have changed the composition of cardiac lesions
phylaxis has been administered. The patient should encountered in parturients. Many patients with congenital
at minimum receive sodium citrate if time does not heart disease are now reaching childbearing age because
allow for the administration of metoclopramide and an of improved surgical treatments. They now constitute an
H2-receptor antagonist. Emphasis should be placed on increasing proportion of pregnant cardiac patients. In
careful positioning of the patient because this can facili- contrast, the number of pregnant patients with rheumatic
tate both mask ventilation and intubation. Towels placed heart disease has declined. Regardless of the cause of
under the shoulders will elevate the shoulders and cause the heart disease, the cardiovascular changes of preg-
the large breasts to fall away from the chin and neck. nancy produce added stress on the already compromised
Towels should also be used under the head to place the cardiovascular system and may result in cardiac decom-
patient in a sniffing position. Because both pregnant and pensation. These patients require close observation and
obese patients rapidly become hypoxemic after the careful management throughout pregnancy, labor, and
onset of apnea, adequate preoxygenation to achieve de- delivery. An interdisciplinary approach that includes obste-
nitrogenation is essential before proceeding with rapid tricians, anesthesiologists, cardiologists, and nurses work-
sequence induction. Three to 5 minutes of tidal ventila- ing closely together optimizes patient care.
tion or four vital capacity breaths with 100% oxygen are
equally effective at providing preoxygenation. The tech-
nique chosen is usually dictated by the urgency with Congenital Heart Disease
which cesarean delivery is required. In the past, few patients with complex congenital
The choice of induction agent is based on the heart disease survived into the childbearing years. With
patients current hemodynamic status and underlying the improvements in the diagnosis and surgical treat-
medical conditions. Most commonly, thiopental 4 mg/kg ment of congenital heart defects that have occurred over
is administered. Succinylcholine is the muscle relaxant of the past 20 years, a significant proportion of pregnant
choice for rapid sequence induction. A dose of 1.0 to cardiac patients in contemporary practice have congen-
1.5 mg/kg should be administered to ensure complete ital heart disease. Many of these women had success-
relaxation during laryngoscopy. Identification of the ful surgical repair of the defects during childhood and
cricoid ring may be difficult in morbidly obese patients. are asymptomatic with normal cardiac function. These
Therefore, it is important that personnel adequately patients often require only standard monitoring and
trained in applying cricoid pressure be available during anesthetic management during labor and delivery, but
induction of general anesthesia. they should undergo cardiology evaluation early during
Anesthesia is usually maintained before delivery of the pregnancy. Echocardiography is beneficial for evaluating
infant with N2O 50% and a volatile halogenated anes- patients for asymptomatic residua of the surgical correc-
thetic agent. After delivery, intravenous opioids can be tion that could be exacerbated by the cardiovascular
administered, and the concentration of volatile agent changes of pregnancy. Some of these patients will require
The High-Risk Obstetric Patient 105
This problem can be prevented by the slow induction of well. Many of the cardiovascular changes of pregnancy
epidural anesthesia, maintenance of adequate preload are deleterious to parturients with moderate to severe
with careful monitoring of CVP, and use of a phenyle- stenosis, however. Therefore, it is recommended that
phrine infusion to maintain SVR. Ropivacaine, levobupi- women with moderate to severe stenosis undergo aortic
vacaine, and 2% lidocaine without epinephrine are all valve replacement before conception.
acceptable local anesthetic choices. Chloroprocaine The increased cardiac output and oxygen consump-
should be avoided because of its rapid onset. Anxiolysis tion and the decreased SVR that occur during pregnancy
with a benzodiazepine may be administered to prevent are deleterious to the patient with severe aortic stenosis.
increases in catecholamine release secondary to mater- Because stroke volume is relatively fixed with the
nal anxiety. Continuous spinal anesthesia is another rea- stenotic lesion, cardiac output increases primarily by an
sonable anesthetic technique for cesarean delivery in increase in heart rate. Tachycardia decreases the time
these patients. Single-shot spinal anesthesia, however, is available for diastolic coronary perfusion and increases
not recommended in patients with Eisenmengers syn- myocardial oxygen demand. The increased left ventricu-
drome because of the hypotension and rapid decrease in lar end-diastolic pressure and left ventricular hypertro-
SVR that could occur. phy that are present in severe aortic stenosis also
Some anesthesiologists advocate general anesthesia decrease myocardial perfusion. The decreased SVR of
for cesarean delivery in women with Eisenmengers syn- pregnancy reduces coronary filling during diastole and
drome. However, disadvantages of this technique do decreases perfusion to the hypertrophied left ventricle.
exist. Decreased venous return associated with positive These parturients are therefore at risk for myocardial
pressure ventilation is not tolerated well in these ischemia. Additional increases in cardiac output occur
patients. In addition, the patients cardiovascular com- during labor and delivery, thus elevating the risk of
promise requires a slow induction of general anesthesia, ischemia even further.
preferably with a high-dose opioid technique, to main- Some obstetricians perform cesarean delivery in these
tain cardiovascular stability. However, these parturients patients only for obstetric indications and prefer a vagi-
are also at risk for pulmonary aspiration. While measures nal delivery. An instrument-assisted vaginal delivery with
such as pharmacologic aspiration prophylaxis and main- minimal maternal expulsive efforts is usually planned to
tenance of cricoid pressure throughout the induction of avoid the adverse hemodynamic effects of the Valsalva
anesthesia will lessen aspiration risk, the risk likely maneuver. Other obstetricians prefer a cesarean delivery
remains higher compared to patients undergoing rapid to avoid the uncertain duration and course, and the
sequence induction. Finally, the use of a high-dose opi- hemodynamic stress of labor. The unique characteristics
oid general anesthetic increases the likelihood of neona- of each patient are used to determine an anesthetic plan.
tal respiratory depression. Regardless of the anesthetic technique chosen, certain
The risk of maternal mortality persists into the post- hemodynamic conditions should be maintained when
partum period. Therefore, extended hemodynamic mon- anesthetizing patients with aortic stenosis. A normal
itoring in an intensive-care setting is essential for at least heart rate and sinus rhythm are essential. Tachycardia is
24 to 48 hours after delivery. Because thromboembolic not well tolerated for the reasons discussed earlier, and
events are a significant cause of maternal death, prophy- bradycardia provides inadequate cardiac output because
lactic anticoagulation should be considered when the of the fixed stroke volume. The atrial kick contributes
risk of bleeding has subsided in the postpartum period. 40% to the ventricular filling and cardiac output. Prompt
treatment is necessary when dysrhythmias occur. Normal
SVR must be maintained to ensure adequate myocardial
Valvular Heart Disease perfusion. Normal venous return is required to maintain
Anesthesiologists are caring for fewer patients with adequate end-diastolic volume and left ventricular stroke
rheumatic valvular disease because the incidence of rheu- volume.
matic fever has markedly decreased in the United States. Invasive monitors, including an intra-arterial catheter
As more women delay childbearing into their fourth and and a CVP or pulmonary artery catheter, are necessary to
fifth decades, however, anesthesiologists should antici- optimize management of these parturients. A pulmonary
pate that they will encounter an increasing number of artery catheter is usually preferable over a CVP catheter.
parturients with aortic stenosis and insufficiency caused The measurements are more indicative of left-sided pres-
by a congenital aortic bicuspid valve. sures, and additional information is provided that is not
available with a CVP catheter.
Aortic Stenosis Although excellent analgesia for labor and vaginal
Aortic stenosis during pregnancy usually results from a delivery is an essential component in the anesthetic man-
congenital bicuspid valve or rheumatic heart disease. agement of women with aortic stenosis, it can be a chal-
Women with mild stenosis generally tolerate pregnancy lenge to provide analgesia and still maintain the
108 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
hemodynamic goals of aortic stenosis. At least in the recommend induction with a slow, high-dose opioid
past, some anesthesiologists avoided regional anesthesia technique. Regardless of the particular drugs chosen for
in these patients because of the decreases in venous induction, the administration of opioids before delivery
return and SVR associated with the technique. Instead, of the infant is necessary to prevent tachycardia during
they utilized intravenous opioids for first-stage labor pain laryngoscopy. Therefore, a neonatologist should be pres-
and pudendal nerve block for second-stage labor pain. ent at delivery. Volatile agents produce myocardial
However, systemic opioids often dont provide adequate depression and should either be avoided or used very
analgesia, and the tachycardia that develops when pain is cautiously. Anesthetic maintenance is best achieved with
inadequately treated is deleterious to these women. Safe a high-dose opioid technique.
and effective labor analgesia can be achieved with slow Patients with moderate to severe aortic stenosis
and careful titration of epidural analgesia, provided that should be monitored closely in the postpartum period.
invasive monitors are utilized to assess and quickly treat Cardiac decompensation could occur in response to the
any decreases in venous return or SVR. Hypotension is marked increase in cardiac output that occurs after deliv-
managed with intravenous fluids and phenylephrine; ery. Therefore, invasive monitoring should continue for
ephedrine is less desirable because of the associated 24 hours after delivery. Excellent postoperative analgesia
tachycardia. is also important in the management of postcesarean
The administration of intrathecal opioids is another patients to prevent tachycardia.
excellent alternative for labor analgesia in women with
aortic stenosis. With a CSE technique, excellent analge- Aortic Insufficiency
sia is initially provided with intrathecal opioids, whereas Rheumatic heart disease is the most common cause of
the decreased venous return and SVR associated with chronic aortic insufficiency in pregnant women. Acute
epidurally administered local anesthetics are avoided. aortic insufficiency may occur in parturients with infec-
When the initial intrathecal analgesia resolves, the slow tive endocarditis. The pathophysiology of aortic insuffi-
administration of epidural local anesthetics provides pain ciency involves left ventricular volume overload that
relief. A continuous spinal catheter technique permits results from regurgitation of blood into the left ventricle
intermittent intrathecal opioid injection throughout the from an incompetent aortic valve. Left ventricular hyper-
first stage of labor. Small doses of intrathecal local anes- trophy and dilation develop. As end-diastolic volume
thetic can be added to the opioid to provide anesthesia increases, ventricular function declines, and forward
for the second stage of labor and delivery. Hemodynamic stroke volume decreases. Progressive deterioration of
stability may be more easily achieved with this technique left ventricular function leads to marked increases of left
compared to epidural anesthesia because a local anes- ventricular end-diastolic volume and pressure, ultimately
thetic-induced sympathectomy is avoided during the leading to pulmonary edema. These changes occur
majority of the labor process. over many years in patients with chronic insufficiency,
Both regional and general anesthesia have been safely so many parturients with aortic insufficiency are asymp-
used to provide anesthesia for cesarean delivery in par- tomatic. However, as an increasing number of women
turients with aortic stenosis. A single-shot spinal tech- delay childbearing into their fourth and fifth decades,
nique is not an acceptable option because of the rapid anesthesiologists may encounter more patients with
hemodynamic changes that may occur. When invasive severe aortic insufficiency.
monitors are used to guide management, the slow admin- The physiologic changes of pregnancy are beneficial to
istration of either epidural or spinal anesthesia via a con- the patient with aortic insufficiency. The reduction in SVR
tinuous catheter technique provides excellent anesthesia decreases the regurgitant fraction and improves forward
and maintains hemodynamic stability. Regional anesthe- stroke volume. The small increase in heart rate decreases
sia avoids the risks of aspiration and difficult intubation time in diastole. As a result, there is less time for regurgita-
that are present in all pregnant women undergoing gen- tion and subsequently a smaller end-diastolic volume.
eral anesthesia. The deleterious effects of tachycardia Patients with mild to moderate aortic insufficiency usually
associated with laryngoscopy are also avoided. tolerate pregnancy well. However, patients with severe
The hypotension and reduction in SVR that could aortic insufficiency in whom significant declines in left
occur with regional anesthesia could be catastrophic in a ventricular function have occurred before pregnancy
parturient with aortic stenosis. Therefore, some anesthe- require intensive management. These patients are often
siologists prefer using general anesthesia for cesarean unable to compensate for the increased blood volume of
delivery in these patients. Anesthetic agents that main- pregnancy. Invasive hemodynamic monitors, including
tain hemodynamic stability should be used. Successful intra-arterial and pulmonary artery catheters, are indi-
induction of general anesthesia with etomidate, alfen- cated for these women during labor and delivery.
tanil, and succinylcholine in a parturient with severe aor- Labor analgesia plays an important role in the manage-
tic stenosis has been reported. Other anesthesiologists ment of parturients with aortic insufficiency. The pain of
The High-Risk Obstetric Patient 109
labor causes an increase in SVR. This increased SVR pro- Careful management by a cardiologist can prevent
duces an increase in left ventricular volume overload, some complications associated with mitral stenosis in
which could lead to pulmonary edema. Epidural analge- parturients. -adrenergic blockade is used to maintain a
sia is an ideal technique for providing pain management slow heart rate. Some controversy exists concerning the
in these patients. Not only does the excellent analgesia effects of -blockers on the fetus. However, one study
attenuate any increases in SVR, but the local anesthetic- found that the administration of -blockers to pregnant
induced sympathetic blockade actually decreases SVR, women with mitral stenosis decreased the incidence of
thereby improving forward stroke volume and cardiac pulmonary edema with no ill effects on the fetus. Atrial
output. In parturients with severe disease, the pul- fibrillation is detrimental in the parturient with mitral
monary artery catheter is helpful in guiding fluid man- stenosis, resulting in decreased cardiac output and an
agement during the induction and maintenance of increased risk of pulmonary edema. Therefore, aggres-
epidural analgesia. Maintaining adequate preload and sive therapy is required. Digoxin and -adrenergic block-
avoiding hypotension are important goals in the anes- ers are administered for both the treatment of atrial
thetic management of these patients. The vasopressor of fibrillation and the maintenance of normal sinus rhythm.
choice for treating hypotension is ephedrine. The If pharmacologic therapy is unsuccessful, cardioversion
increase in heart rate associated with this drug is benefi- is performed.
cial. In contrast, the bradycardia and increased SVR asso- Patients with asymptomatic, mild to moderate mitral
ciated with phenylephrine use could be detrimental. stenosis generally tolerate labor and delivery well. It is
For the same reasons described for labor analgesia, prudent to observe these patients closely during labor
epidural anesthesia is the preferred technique for cesarean and maintain continuous pulse oximetry monitoring, but
delivery in patients with aortic insufficiency. Slow adminis- invasive monitoring is usually not warranted. Invasive
tration of local anesthetic and the use of invasive monitors monitoring that includes a pulmonary artery catheter
to guide fluid and vasopressor management are essential. is recommended in patients who either become sympto-
Cardiac arrest has been reported in a parturient with aortic matic during pregnancy or have severe stenosis. Adequate
insufficiency when the epidural block was established too filling pressures should be maintained in these patients,
quickly. If the clinical situation requires general anesthesia, but fluid overload must also be avoided because they are
the severity of the patients condition determines the type at significant risk for pulmonary edema, especially in the
of anesthetic induction. Asymptomatic women with mild immediate postpartum period. Maintenance of SVR is
to moderate insufficiency tolerate a rapid sequence induc- necessary to provide adequate perfusion pressure
tion. A slow induction with high-dose opioids is recom- because the ability to increase cardiac output is limited
mended for patients with severe insufficiency and left by the stenotic lesion. These patients may not tolerate a
ventricular dysfunction. Anesthetic agents that depress sudden increase in venous return associated with the
myocardial function should be avoided or used cautiously Valsalva maneuver during maternal expulsive efforts.
in parturients with severe disease. A passive second stage of labor and instrument-assisted
vaginal delivery are often planned. Cesarean delivery is
Mitral Stenosis usually reserved for obstetric indications.
Although the incidence of rheumatic heart disease has Excellent analgesia to prevent the undesirable tachy-
declined significantly in the United States, mitral stenosis cardia associated with labor pain is an important goal in
is the most common cardiac lesion associated with rheu- the anesthetic management of parturients with mitral
matic heart disease in pregnant women. Therefore, anes- stenosis. In addition, a dense anesthetic block is required
thesiologists who care for high-risk obstetric patients are during the second stage of labor to prevent the urge to
likely to encounter patients with this valvular disorder. In push and to facilitate a forceps- or vacuum-assisted deliv-
25% of women with mitral stenosis, the first symptoms ery. A CSE anesthesia technique is one reasonable alter-
occur during pregnancy, precipitated by the cardiovas- native for these patients. Intrathecal opioid can provide
cular changes of pregnancy. The necessary increase in initial analgesia during the first stage of labor without
cardiac output during pregnancy is impeded by the producing a significant drop in SVR or requiring a large
stenotic lesion. In addition, the heart rate increase that fluid bolus to maintain adequate preload. As additional
occurs during pregnancy decreases the diastolic time for labor analgesia and anesthesia for delivery are required,
left ventricular filling. This leads to increases in left atrial slow incremental dosing of the epidural catheter accom-
and pulmonary arterial pressures and ultimately to pul- panied by close observation of the hemodynamic moni-
monary edema. Parturients with severe mitral stenosis tors will minimize disastrous decreases in SVR and
do not tolerate well the increased demands placed on the venous return while also preventing inadvertent volume
cardiovascular system and are likely to experience car- overload. Phenylephrine is preferred over ephedrine to
diac decompensation. These patients should be closely treat anesthesia-induced hypotension because it main-
monitored by a cardiologist throughout pregnancy. tains SVR and avoids maternal tachycardia. Continuous
110 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
epidural and spinal analgesia are also reasonable options logic changes of pregnancy, including decreased SVR
for providing labor analgesia to patients with severe and mildly increased heart rate, are advantageous in
mitral stenosis. Monitoring and hemodynamic manage- patients with mitral insufficiency. Most patients tolerate
ment are similar regardless of the regional anesthesia pregnancy well.
technique chosen. Continuous electrocardiographic monitoring is war-
Epidural anesthesia is often the preferred technique ranted during labor and delivery because of the increased
for cesarean delivery in patients with mitral stenosis. risk for atrial fibrillation. If atrial fibrillation does occur,
Using invasive monitors to guide fluid management, the rapid treatment is essential to maintain adequate cardiac
slow induction of epidural anesthesia is generally well- output. No other special monitoring is necessary for
tolerated with maintenance of hemodynamic stability. asymptomatic patients during labor and delivery.
A significant sympathectomy does occur with the high Symptomatic patients and patients with a history of pul-
sensory level required to provide adequate anesthesia for monary edema require invasive monitoring with an intra-
cesarean delivery. Phenylephrine is administered by arterial catheter and pulmonary artery catheter.
slow infusion or small, intermittent doses to prevent a Increased SVR caused by either labor pain or the
hemodynamically significant reduction in SVR. A single- Valsalva maneuver during expulsive efforts must be
shot spinal technique is not recommended for parturi- avoided. Epidural anesthesia provides excellent labor
ents with severe mitral stenosis because of the potential analgesia and anesthesia for an instrument-assisted deliv-
for large, rapid declines in venous return and SVR. ery while also preventing an undesired increase
Some clinical scenarios will require general anesthesia in SVR. In fact, the technique produces a mild reduction
for cesarean delivery in patients with mitral stenosis. The in SVR, which reduces regurgitation, improves forward
patients ventricular function determines if she will toler- flow, increases cardiac output, and decreases the likeli-
ate a rapid-sequence induction of general anesthesia, or hood of developing pulmonary edema. Careful attention
will require a high-dose opioid technique. A -adrenergic is given to maintaining adequate venous return and left
blocker or a small dose of opioid is administered during ventricular filling during epidural anesthesia. CSE analge-
rapid-sequence induction to blunt tachycardia and hyper- sia is another acceptable technique for providing labor
tension associated with laryngoscopy. Remifentanil may analgesia to patients with mitral insufficiency. However,
be a good choice when a high-dose opioid technique is the use of epidural local anesthetics is usually preferred
used because its rapid metabolism and very short dura- over spinal opioids because of the advantageous decrease
tion of action could minimize depressant effects in the in SVR that occurs with local anesthetic-induced sympa-
neonate. In fact, in one case in which remifentanil was thectomy.
used for cesarean delivery in a woman with mitral valve Epidural anesthesia is usually the anesthetic of choice
disease, no neonatal depression occurred. for cesarean delivery in women with mitral insufficiency.
The marked increases in cardiac output and venous A continuous spinal anesthetic also provides cardiovas-
return that occur in the immediate postpartum period cular effects that are advantageous, but the increased
put patients with severe mitral stenosis at high risk for incidence of spinal headache does not justify its use
developing pulmonary edema. Therefore, these patients over epidural anesthesia in most patients. Ephedrine is
require close observation and continued hemodynamic the vasopressor of choice for treating hypotension.
monitoring for at least 24 hours postpartum. The anes- Phenylephrine is avoided because the increased SVR and
thesiologist may choose to continue epidural anesthesia decreased heart rate associated with its use are deleteri-
for several hours postpartum so that the increased pre-
load associated with resolution of the sympathectomy-
induced vasodilation will not coincide with the CLINICAL CAVEAT: HEMODYNAMIC GOALS IN
increased preload that occurs in the immediate postpar- PARTURIENTS WITH VALVULAR HEART DISEASE
tum period. Aortic stenosis: Maintain normal heart rate and sinus
rhythm; avoid decreases in SVR; maintain normal
Mitral Insufficiency venous return.
The majority of parturients with mitral insufficiency Aortic insufficiency: Maintain normal to slightly
have chronic insufficiency caused by rheumatic heart increased heart rate; avoid increases in SVR.
disease or mitral valve prolapse. Slow dilation of the left Mitral stenosis: Maintain slow heart rate and sinus
rhythm, maintain normal SVR; maintain normal
atrium develops as left atrial pressure increases. Like par-
venous return.
turients with mitral stenosis, the risk of developing atrial
Mitral insufficiency: Maintain sinus rhythm and
fibrillation during pregnancy is increased. The incidence normal to slightly increased heart rate; avoid
of pulmonary edema and pulmonary hypertension, how- increases in SVR and venous return; maintain normal
ever, is much lower in pregnant women with mitral venous return.
insufficiency compared to mitral stenosis. The physio-
The High-Risk Obstetric Patient 111
ous to parturients with mitral insufficiency. When gen- confirms ventricular failure with increased left ventricular
eral anesthesia is required for cesarean delivery, anes- end-diastolic dimensions and decreased ejection fraction.
thetic agents that produce decreased afterload and a Once cardiac failure is identified, peripartum cardiomy-
slightly increased heart rate are chosen. Drugs with opathy must be differentiated from other cardiac
myocardial depressant effects are avoided. processes that lead to heart failure.
Maternal mortality from peripartum cardiomyopathy
in the United States has been reported to be 25% to 50%.
Peripartum Cardiomyopathy Thromboembolism accounts for approximately 30% of
Peripartum cardiomyopathy is a rare but life-threatening these deaths. Patients who survive the disease have a sig-
disease. The currently accepted incidence is approxi- nificantly higher ejection fraction and smaller left ven-
mately 1 per 3000 to 1 per 4000 live births. However, an tricular end-diastolic diameter at the time of diagnosis
increasing proportion of maternal deaths in the United compared with patients who succumb. Normalization of
States was attributed to peripartum cardiomyopathy in the heart size and resolution of congestive heart failure
1990s. Identified risk factors for peripartum cardiomyopa- within 6 months after delivery are also good prognostic
thy include advanced maternal age, multiparity, obesity, signs, with mortality rare among these patients.
multiple gestation, pre-eclampsia, chronic hypertension,
and African-American race. Peripartum cardiomyopathy is Medical and Obstetric Management
defined by the presence of four criteria (Box 8-9). Medical treatment of peripartum cardiomyopathy
The etiology of peripartum cardiomyopathy remains is similar to that for other dilated cardiomyopathies.
unknown, despite much investigation that has focused on Management goals include preload optimization, afterload
identifying a cause. Proposed etiologies include myocardi- reduction, and increased contractility. Anticoagulation is
tis, abnormal immune response to pregnancy, and mal- also considered in many patients because of the significant
adaptive response to the hemodynamic stresses of risk of thromboembolism. When the patient develops
pregnancy. There is more evidence to support myocarditis cardiac failure while still pregnant, some treatment modifi-
or an autoimmune process as the cause of the disease than cations are required. Angiotensin-converting enzyme
for other proposed etiologies. Endomyocardial biopsies in inhibitors are routinely used for afterload reduction in
women with peripartum cardiomyopathy have demon- congestive heart failure. However, these drugs are con-
strated myocarditis in many patients, but biopsy results traindicated during pregnancy because of adverse fetal
differ markedly among studies. effects. Alternative treatments for afterload reduction dur-
Patients with peripartum cardiomyopathy present ing pregnancy include amlodipine or a combination of
with the typical signs and symptoms of left ventricular hydralazine and nitroglycerin.
failure. The majority of cases occur after delivery and the In addition to treatment of the cardiac failure,
immediate postpartum period. However, when the dis- an obstetric plan of care must also be developed.
ease develops during the last month of pregnancy, the Collaboration among the obstetrician, cardiologist, and
diagnosis of cardiac failure is difficult to make by signs anesthesiologist is essential to optimize care. If the par-
and symptoms alone because some of the symptoms, turients cardiac status can be stabilized with medical
such as fatigue, orthopnea, and pedal edema, are com- therapy, induction of labor is usually recommended,
mon among normal parturients during late pregnancy. with cesarean delivery reserved for obstetric indications.
Further testing is required to establish the presence of However, in parturients who experience acute cardiac
cardiac failure. A chest x-ray consistently demonstrates decompensation, cesarean delivery may be required
cardiomegaly and pulmonary edema. Echocardiography because of an inability of the mother to tolerate the pro-
longed stresses of labor.
in uncomplicated term pregnancies. JAMA 287:26842690, Weiss BM, Atanassoff PG: Cyanotic congenital heart disease and
2002. pregnancy: Natural selection, pulmonary hypertension, and
anesthesia. J Clin Anesth 5:332341, 1993.
Tsen LC: Anesthetic management of the parturient with cardiac
and diabetic diseases. Clin Obstet Gynecol 46:700710,
2003.
9
CHAPTER Obstetric
Anesthesiology
Services
FERNE R. BRAVEMAN
114
Obstetric Anesthesiology Services 115
Box 9-1 Optimal Goals for Anesthesia Box 9-3 Guidelines for Regional
Care in Obstetrics Anesthesia in Obstetrics
From Optimal Goals for Anesthesia Care in Obstetrics. Approved by the ASA
House of Delegates on October 18, 2000.
Box 9-4 ACOG Recommendations Box 9-5 Vaginal Birth After Previous
Regarding Obstetric Analgesia Cesarean Delivery
SUGGESTED READING
Box 9-7 Need for Postpartum ICU Care
American College of Obstetrics and Gynecology Practice
Bulletin. Clinical management guidelines for obstetrician-
Complications from pre-eclampsia gynecologists. Vaginal Birth After Previous Cesarean Delivery.
Pulmonary edema Number 5, July 1999.
Seizures
Hemorrhage American College of Obstetrics and Gynecology Practice
Comorbid disease Bulletin. Clinical management guidelines for obstetrician-
Cardiac gynecologists. Obstetric Analgesia and Anesthesia. Number
Asthma 36, July 2002.
American Society of Anesthesiologists Task Force on
Obstetrical Anesthesia: Practice guidelines for obstetrical
anesthesia: A report by the American Society of Anesthesio-
Box 9-8 Factors Prompting Anesthetic logists Task Force on Obstetrical Anesthesia. Anesthesiology
Consultation 90:600611, 1999.
American Society of Anesthesiologists Task Force on
Morbid obesity Postanesthetic Care: Practice guidelines for postanesthetic
Severe facial/neck/spinal abnormalities care: A report by the American Society of Anesthesiologists
Serious maternal medical disease Task Force on Postanesthetic Care. Anesthesiology 96:742752,
Cardiac 2002.
Pulmonary Hawkins JL, Gibbs CP, Orleans M, et al: Obstetric anesthesia
Neurologic work force survey, 1981 versus 1992. Anesthesiology 87(1):
135143, 1997.
requested by the patients obstetrician, to allow the
safest care for patients with significant comorbid
disease (Box 9-8).
REFERENCE
1. American Society of Anesthesiology/American College of
Obstetrics and Gynecology: Statement on Pain Relief
During Labor. Approved October 13, 1999.
10
CHAPTER Complication and Risk
Management in
Obstetrics and
Gynecologic
Anesthesia
NALINI VADIVELU
118
Complication and Risk Management in Obstetrics and Gynecologic Anesthesia 119
better pain relief than systemic opioids, as assessed by epidural analgesia remains unclear. Several hypotheses
the verbal analog score. However, a major concern regard- have been developed to explain this. One hypothesis is
ing epidural analgesia is its effect on the progress of labor, that the motor blockade in association with epidural
leading to increased incidence of cesarean delivery, vaginal analgesia may prevent the mother from pushing, thereby
delivery requiring the use of forceps or vacuum extrac- necessitating the use of instruments. Epidural analgesia
tion, or prolongation of labor. Instrument-assisted deliv- is also associated with a higher frequency of the occiput
eries and cesarean deliveries may be associated with a posterior position of the fetus at delivery, which could
greater incidence of maternal complications than unas- also represent a mechanism by which epidural analgesia
sisted vaginal deliveries. The rate of instrument-assisted contributes to the higher rate of instrument-assisted
vaginal deliveries is associated with a higher rate of seri- delivery. In addition, it is possible that the presence of an
ous perineal lacerations, which has been implicated as a epidural block may decrease the obstetricians threshold
risk factor for later fecal incontinence. Instrument-assisted for performing instrument-assisted deliveries as well as
vaginal deliveries have also been linked to higher rates of allowing instrument-assisted delivery for the purpose of
neonatal birth injuries. teaching residents.
A recent prospective, randomized meta-analysis repre- Studies of sentinel events have shown that epidural
sents the experience of nearly 2400 patients randomly analgesia may prolong labor by approximately 1 hour on
assigned to receive either epidural analgesia or par- average. Most observational studies demonstrate higher
enteral opioid analgesia. Epidural analgesia was associ- rates of cesarean delivery with early administration of
ated with a prolongation of the second stage of labor by epidural analgesia. There is, however, insufficient evi-
an average of 14 minutes. No significant difference dence to determine the impact of waiting until a certain
between groups in the rate of cesarean delivery could be degree of cervical dilatation or a certain fetal station is
demonstrated by intention to treat analysis (8.2% of reached before instituting epidural analgesia (Box 10-1).
women in the epidural group had cesarean deliveries as
compared with 5.6% in the parenteral opioid group).
It is important to realize that the effect of epidural COMPLICATIONS OF REGIONAL
analgesia on the likelihood of cesarean delivery may vary ANESTHESIA
according to obstetric practice and the population stud-
ied and that such variations may influence the differ- Maternal Fever
ences observed in various studies. Studies have clearly The association between the use of epidural analgesia
demonstrated great variations in physician-specific rates and maternal fever is complex. Some authors assert that
of cesarean delivery, suggesting that management prac- the increase in the frequency of fever is the result of pla-
tices are certainly a confounding variable. In a study by cental infection, as assessed by neutrophilic infiltration
Goyert et al.1 of 1533 parturient women who were cared of the placenta, possibly associated with the longer dura-
for by 11 obstetricians, the rate of cesarean delivery var- tion of labor among women who receive epidural analge-
ied from 19% to 41% depending on the caregiver. An sia. This explanation seems unlikely because women
additional variable that may account for the varying with long labors but no epidural analgesia do not tend to
cesarean section rates among study participants is that have higher incidents of fever. The rate of sepsis among
women enrolled in many of the randomized trials were term infants is equally low, whether or not the mother
much younger than the general population of women receives epidural analgesia.
delivering babies in the United States. Studies have also
consistently demonstrated an increase in the rate of
cesarean delivery with an increase in age. Therefore, Back Pain
there is no definite conclusion whether epidural analge- There is a concern among many parturients that
sia is an independent variable with respect to increases epidural analgesia may lead to back pain. Howell et al.2
in the rate of cesarean deliveries.
There seems to be a clearer association between
instrument-assisted delivery and epidural analgesia; there Box 10-1 Adverse Events That Have
is a consistent increase in the rates of deliveries involving Been Associated With Regional
forceps and vacuum extraction in patients receiving Labor Analgesia
epidural analgesia. A meta-analysis of randomized trials
found a doubling of the rate of instrument-assisted vagi- Increase in instrumented vaginal deliveries
nal deliveries. A recent randomized trial found an Increase in cesarean deliveries
increase in the rate of deliveries involving forceps from Prolonged duration of labor
3% in the opioid group to 12% in the epidural analgesia Fetal occiput posterior presentation
group. The exact reason for this increase seen with
120 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
studied 385 nulliparous parturient women for 12 formed. The effectiveness of an epidural blood patch to
months after delivery and demonstrated no difference in treat postdural puncture headache is well recognized.
the incidence of backache between women who were More than 75% of women with postdural puncture
randomly assigned to receive epidural analgesia and headache managed with an epidural blood patch as a sec-
those who were not. The results of other nonrandom- ondary treatment were effectively treated. A second blood
ized trials are consistent with these findings. In contrast, patch produced complete relief in approximately 95% of
studies have provided evidence that postpartum back patients. If the headache does not have the pathogno-
pain is most likely to be a continuation of antepartum monic postural characteristics or persists despite treat-
pain. In a study by Breen3 in 1994, new onset back pain ment with an epidural blood patch, other diagnoses must
was associated with greater weight and short stature and be considered and appropriate testing performed.
not with the number of attempts at epidural placement. Short- and long-term symptoms, particularly headache,
have been attributed to dural puncture for spinal anesthe-
sia. The improved needle design with pencil-pointed tips
Neurologic Complications After Regional has resulted in a decrease in the incidence of postdural
Anesthesia puncture headache (PDPH) and the increase in the popu-
A recent survey conducted in the United Kingdom larity of spinal anesthesia in obstetric practice. The inci-
that included 42,000 neuroaxial blocks in pregnant dence of postdural puncture headache using a 25-gauge
patients reported no differences between the incidence Whitacre needle or a smaller needle for spinal anesthesia
of epidural abscess and spinal hematoma associated with is lower than when a larger diameter needle is used for
CSE versus single-shot spinal anesthesia. In obstetrics, the administration of spinal anesthesia.
although neurologic complications may be secondary Not every headache occurring after childbirth in
to the labor and delivery processes, the neural block is patients with a history of neuraxial block is secondary to
usually considered to be causative until proven other- dural puncture. The differential diagnoses of persistent
wise. It is important to recognize that spontaneous headache that occurs in the puerperium include spinal
neurologic complications may occur unrelated to headache after regional anesthesia, nonspecific headache,
regional anesthesia; spontaneous epidural abscesses of migraine, meningitis, pregnancy-induced hypertension
unknown etiology have been seen in obstetric patients. associated with headache, cerebral tumor subarachnoid
Monitoring, early diagnosis, and prompt treatment of hemorrhage, subdural hematoma, and cerebral vein
neurologic complications will usually lead to complete thrombosis. There are contradictory reports on long-term
resolution of neurologic deficit in cases of epidural headaches following dural puncture.
abscess and epidural hematoma.
Neonatal Effects
Postdural Puncture Headache It has been demonstrated that women who receive
Techniques that lead to puncture of the dura have epidural analgesia are more likely to have a fetus in the
a small but clinically significant risk for headache in the occiput posterior position at delivery. It is not clear, how-
parturient (Box 10-2). Norris et al.4 have shown that inad- ever, whether the use of epidural analgesia contributes to
vertent puncture of the dura mater during placement of an the persistence of this position or whether women with
epidural catheter occurs in about 3% of parturients, and a a fetus in this position are more likely to request epidural
severe headache occurs in up to 70% of women with such analgesia secondary to painful labors. Other neonatal
a puncture. Dural puncture rates have been shown to be effects that have been reported in connection with
inversely proportionate to the number of epidurals per- epidural analgesia include effects for which inadequate
data are available to draw definitive conclusions.
The use of crystalloid for fluid preload has not been There are several studies in which maternal death cer-
totally effective in preventing spinal hypotension. tificates have been reviewed to assess maternal mortality
Several authors have reported a lack of clinically signifi- rates. Often, death certificates do not provide enough
cant reduction in spinal hypotension following fluid pre- detail to accurately classify the pathophysiology leading
load. No clinical advantage of warmed crystalloid preload to maternal death or to determine contributing risk fac-
as compared with cold infusions with regard to inci- tors. The degree of underreporting of maternal death
dence of hypotension has been detected so far, although rates by routine vital statistics has been estimated to be
it can be argued that comfort of the patient favors the use 20% to75%.
of warmed infusions. Anesthesia-associated maternal mortality is between
There is controversy regarding the use of colloids to 4.3 and 1.7 per 1 million live births in the United States.
prevent hypotension with spinal anesthesia in the par- This is the sixth leading cause of pregnancy-related
turient. Several reports highlighted advantages of colloid deaths in the United States. General anesthesia is associ-
preload. Hydroxyethyl starch has been suggested for use ated with a higher risk of airway problems in women
in the prevention of spinal hypotension. undergoing cesarean delivery when compared to nonob-
When comparing therapies, the costs and side effects stetric patients. Studies have shown that the risk of
of colloid solutions must be balanced against any failed intubation is estimated as 1 in 200 to 1 in 300
improved outcome and against the costs and clinical cases, about 10 times higher than that seen in nonobstet-
value of prophylactic administration of vasopressors. ric patients. Most anesthesia-related deaths occur during
Ephedrine is the preferred agent for normalizing blood general anesthesia for cesarean delivery. The risk of
pressure, although some data suggests phenylephrine maternal deaths resulting from complications of general
may be a better choice. There is a lack of consensus anesthesia is 17 times higher than that associated with all
regarding the appropriate route, dosage, and timing of types of regional anesthesia. In addition to failed intuba-
ephedrine and/or phenylephrine administration. tion, pulmonary aspiration related to general anesthesia
and subsequent respiratory failure may also lead to
maternal death.
MATERNAL MORTALITY AND GENERAL
ANESTHESIA
CLINICAL CAVEAT
Maternal death has been defined by the Bureau of Vital
General anesthesia is associated with a higher risk of
Statistics as the death of a woman while pregnant or
airway problems in the obstetric patient versus the
within 42 days of termination of pregnancy, despite dura-
general surgical patient.
tion and the site of pregnancy, from any cause related to or
aggravated by the pregnancy or its management but not
from accidental or incidental causes. The American Regional anesthesia may be preferable to general anes-
College of Obstetrics and Gynecologists (ACOG) has thesia even when the status of the fetus is not reassuring,
defined maternal death as the death of any woman that as it may be safer for the mother. Recognition of the risks
was caused or contributed to by pregnancy, occurring dur- to the mother associated with general anesthesia has
ing pregnancy, or within 1 year after the end of pregnancy. resulted in an increase in the use of spinal or epidural
A retrospective analysis in 2001 using a Maryland State anesthesia for both elective and emergency cesarean
database attributed 5.2% of maternal deaths to anesthesia- deliveries. This shift in practice over the last decade has
related complications. The death of a woman during preg- led to a decrease in maternal mortality rates.
nancy or in the period after pregnancy presents a wide The Committee on Obstetric Practice of the American
array of problems for her family and the community. College of Obstetricians and Gynecologists has recom-
Maternal death is a particularly tragic event because mended that a management plan be developed jointly by
pregnant women are usually young and healthy. The obstetricians and anesthesiologists if risk factors and
Centers for Disease Control and Prevention (CDC) has signs predicting a difficult intubation are present.
estimated that current overall maternal mortality ratio
(MMR), defined as the number of deaths per 100,000 live
births, to be 7.5. The goal of the United States Public INFORMED CONSENT REGARDING
Health Service 2000 Project was to achieve a 50% reduc- RISKS AND COMPLICATIONS OF
tion in the MMR (6.7). In the United States, there are five OBSTETRIC ANESTHESIA
main sources for identifying maternal deaths. These
include published vital records, manual review of death Informing patients of the possible risks and complica-
certificates, vital records linkage, review of autopsy tions of obstetric anesthesia is essential to their care. It is
reports, and review of medical records. best done in advance of labor. Detailed and accurate
122 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
explanations of any and all potential risks, combined also reflects the consumers perspective. It provides a
with written documentation of this discussion are pre- valuable insight into the types and patterns of injury asso-
ferred. ciated with malpractice claims.
A study done by Jackson et al.5 on 60 laboring women
showed that laboring women wanted to hear about all
potential epidural complications, but the majority did OBSTETRIC ANESTHESIA CLOSED
not want specific incidences quoted. In the majority of CLAIMS
cases, no side effect disclosed during the consent process
dissuaded a parturient once the request for an epidural There have been changes in patterns of claims in
was made. It seemed that laboring women were indeed obstetric anesthesia recently because of the changes in
capable of giving informed consent. anesthesia practice in the last three decades. Over the
past 33 years, there has been a decrease in cesarean
deliveries performed under general anesthesia and an
ASA CLOSED CLAIMS FOCUSING ON increase in cesarean deliveries performed under
OBSTETRIC COMPLICATIONS regional anesthesia. A paper by Davies et al.6 in 2004
indicated that approximately 12% (792) of the 6449
The ASA closed claims project is an in-depth study of claims in the ASA Closed Claims Project database
claims against anesthesiologists based upon data col- involved obstetric anesthesia care. Of these obstetric
lected from the files of 35 professional liability insurance claims, about two thirds involved claims related to
carriers in the United States. The project is conducted cesarean section, and 33% of the claims involved vaginal
under the auspices of the ASA Committee on Professional deliveries. Concomitant with the increase in the propor-
Liability. Much has been learned from the Obstetrical tion of cesarean sections done under regional anesthesia
Anesthesia Closed Claims about liability and anesthesia is an increase in the proportion of claims associated
risk since 1984, when the Committee on Professional with regional anesthesia along with a decline in claims
Liability of the American Society of Anesthesiologists associated with general anesthesia since the anesthesia
began this ongoing study. The outcome of this project work force survey was done in 1981.
has been the issuance and revision of standards and pro-
cedures for anesthesia care to avoid further morbidity
and/or mortality. Aspiration Pneumonitis
In the offices of professional liability insurance carriers, An analysis of obstetric anesthesia cases from the
practicing anesthesiologists reviewed files of claims that ASA Closed Claims Project database 1996 showed that
were no longer active (close claims). A standardized almost all the obstetric claims in which pulmonary
data-collection instrument was completed according to a aspiration was identified as the primary damaging
set of instructions provided to each reviewer for claims in event occurred in association with general anesthesia.
which there was enough information to reconstruct the Aspiration accounted for only 31% of obstetric files but
sequence of events leading to injury and the nature of 76% of nonobstetric files. Pulmonary aspiration was
injury. Claims for dental damage were not included. noted in 7% of the obstetric files but was not always
Typical files that were reviewed included hospital and considered the primary damaging event. In 25 of these
anesthesia records, narrative statements from the person- cases, the primary anesthetic technique was general
nel involved, expert and peer reviews. Deposition sum- anesthesia. In 10 cases, aspiration occurred during dif-
maries, outcome reports, and data concerning cost of ficult intubation or following esophageal intubation;
settlement or award were also examined. The data collec- and in seven cases, mask general anesthesia was being
tion instrument consisted of several items, including the used. In three cases, vomiting and aspiration occurred
ASA physical status and description of the patient, date at the time of induction without cricoid pressure. Two
and time of incident, type of procedure, type of anesthesia cases of aspiration were associated with cricoid pres-
personnel, the anesthetic technique and agents, complica- sure. Two cases of aspiration associated with regional
tions or injuries, and whether the complaint was related anesthesia occurred during resuscitation and intuba-
to the anesthetic in any way. For each claim in which suf- tion following high spinal blocks. In two other cases,
ficient information was available, reviewers were asked to heavy sedation was implicated. The Obstetric Closed
judge the quality of anesthetic care based on the standard Claims files from 1996 indicate that damaging events
of care that a reasonable and prudent anesthesiologist related to the respiratory system were significantly
would have exercised at the time of the event. The out- more common among obese (32%) than nonobese (7%)
come of this project was the issuance of recommenda- parturients. However, the overall number of claims for
tions is for care directed at injury avoidance. The aspiration pneumonitis has decreased from 9% in
uniqueness of the ASA Closed Claims database is that it 1970s to 1% in 1990s.
Complication and Risk Management in Obstetrics and Gynecologic Anesthesia 123
Headache
The percentage of headache claims has increased Newborn Death
from 12% in the 1970s to 14% in the 1990s. The popular- Anesthesiologists must be aware that they can be
ity of regional anesthesia techniques in obstetrics com- implicated in newborn death, even if the cause is obstet-
bined with the greater incidence of postlumbar puncture ric. Claims for newborn deaths have risen from 1% in the
headaches in the young female population likely account 1970s to 6% in the 1990s.
124 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
4. Norris MC, Joseph J, Leighton BL: Anesthesia for perinatal Hawkins JL, Koonin LM, Palmer SK, Gibbs CP: Anesthesia-related
surgery. Am J Perinatol 6(1):3940, 1989. deaths during obstetric delivery in the United States, 1979-
5. Jackson A, Henry R, Avery N, et al: Informed consent for 1990. Anesthesiology 86(2):277284, 1997.
labour epidural: What labouring women want to know. Can Hawkins JL, Gibbs CP, Orleans M, et al: Obstetric anesthesia
J Anesth 47(11):10681073, 2000. work force survey, 1981 versus 1992. Anesthesiology 87(1):
6. Davies J: Obstetric anesthesia closed claimstrends over 135143, 1997.
the last three decades. ASA Newsletter, June 2004. Hickson GB, Clayton EW, Githens PB, Sloan FA: Factors that
prompted families to file medical malpractice claims follow-
ing perinatal injuries. JAMA 267(10):13591363, 1992.
SUGGESTED READING
Khor LJ, Jeskins G, Cooper GM, Paterson-Brown S: National
Atrash HK, Alexander S, Berg CJ: Maternal mortality in devel- obstetric anaesthetic practice in the UK 1997/1998.
oped countries: Not just a concern of the past. Obstet Anaesthesia 55(12):11681172, 2000.
Gynecol 86(4 Pt 2):700705, 1995. Kubli M, Scrutton MJ, Seed PT, OSullivan G: An evaluation of
Berg CJ, Atrash HK, Koonin LM, Tucker M: Pregnancy-related isotonic sport drinks during labor. Anesth Analg 94(2):
mortality in the United States, 19871990. Obstet Gynecol 404408, 2002.
88(2):161167, 1996. Towner D, Castro MA, Eby-Wilkens E, Gilbert WM: Effect
Chadwick HS, Posner K, Caplan RA, et al: A comparison of of mode of delivery in nulliparous women on neonatal
obstetric and nonobstetric anesthesia malpractice claims. intracranial injury. N Engl J Med 341(23):17091714,
Anesthesiology 74(2):242249, 1991. 1999.
Halpern SH, Leighton BL, Ohlsson A, et al: Effect of epidural vs Wong CA, Scavone BM, Peaceman AM, et al: The risk of cesarean
parenteral opioid analgesia on the progress of labor: A meta- delivery with neuroaxial analgesia given early vs late in labor.
analysis. JAMA 280(24):21052110, 1998. N Eng J Med 352(7):655665, 2005.
11
CHAPTER Pharmacology and
Physiologic Issues
Specific to the Care
of the Gynecologic
Patient
MIRJANA LOVRINCEVIC
Surgical Anatomy of the Female Pelvis distribution of innervation to the viscera: the vesical
Physiology of the Ovarian Hormones plexus, which innervates the bladder and urethra; hem-
Estrogens orrhoidal plexus, which innervates the rectum; and
Progesterone uterovaginal plexus (Frankenhusers ganglion), which
Psychology of the Gynecologic Patient provides innervation to the uterus, vagina, clitoris, and
Gynecologic Malignancies vestibular bulbs. Parasympathetic innervation comes
from the second, third, and fourth sacral nerves in the
form of nervi erigentes. Pelvic viscera also have nocicep-
tive synapses from T10 to L1 spinal levels and the celiac
SURGICAL ANATOMY OF THE FEMALE plexus.
PELVIS The lumbosacral plexus and its branches provide
motor and sensory somatic innervation to the lower
The organs of the female pelvis are the bladder, ureters, abdominal wall, the pelvic and urogenital diaphragms,
urethra, uterus, fallopian (uterine) tubes, ovaries, vagina, the perineum, and the hip and lower extremity. A visceral
and rectum. These organs do not completely fill the cav- component, the pelvic splanchnic nerve, is also included
itythe remaining space is occupied by ileum and sig- (Table 11-1).
moid colon. The uterus, fallopian tubes, and ovaries are
almost completely covered with peritoneum, while the
rest of the organs in the pelvis are partially covered. PHYSIOLOGY OF THE OVARIAN
The blood supply to pelvic organs is primarily from HORMONES
the internal iliac (hypogastric) artery and its visceral
branches: uterine artery; superior, middle, and inferior Unlike the reproductive system of men, the reproduc-
vesical arteries supplying the bladder; the middle and tive system in women undergoes regular cyclic changes
inferior hemorrhoidal artery; and the vaginal artery. under the influence of female hormones: estrogens and
However, collateral circulation is rather generous and progesterone.
arises from the aorta in the form of the ovarian artery,
from the external iliac artery and from the femoral artery.
The veins form extensive plexus that drains into the Estrogens
hypogastric trunk. The lymphatic channels of the female The naturally occurring estrogens are 17-estradiol,
reproductive organs drain predominantly into the pelvic estrone, and estriol. They are secreted primarily by the
and para-aortic lymph nodes. granulosa and the thecal cells of the ovarian follicles, the
The pelvic organs are innervated by both sympathetic corpus luteum, and the placenta, although they are also
and parasympathetic nerves. The superior hypogastric formed from androgens by biotransformation.
plexus carries the majority of sympathetic fibers. They 17-estradiol is the primarily secreted estrogen and
originate in the first, second, third, and fourth lumbar the most potent. It is 98% protein bound, with 2% circu-
nerves and are responsible for the innervation of the lating free. Estrone is in equilibrium in the circulation
fundus uteri, cervix, and vagina. The inferior hypogas- with 17-estradiol and is metabolized in the liver to
tric plexus is divided into three portions, representing estriol, the least potent estrogen.
126
Pharmacology and Physiologic Issues Specific to the Care of the Gynecologic Patient 127
Iliohypogastric T12, L1 Sensoryskin near iliac crest, just above symphysis pubis
Ilioinguinal L1 Sensoryupper medial thigh, mons, labia major
Lateral femoral cutaneous L2, L3 Sensorylateral thigh to level of knee
Femoral L2, L3, L4 Sensoryanterior and medial thigh, medial leg and foot, hip, and knee joints
Motoriliacus, anterior thigh muscles
Genitofemoral L1, L2 Sensoryanterior vulva (genital branch), middle and upper anterior
thigh (femoral branch)
Obturator L2, L3, L4 Sensorymedial thigh and leg, hip, and knee joints
Motoradductor muscles of thigh
Superior gluteal L4, L5, S1 Motorgluteal muscles
Inferior gluteal L4, L5, S1, S2 Motorgluteal muscles
Posterior femoral cutaneous S2, S3 Sensoryvulva, perineum
Sciatic L4, L5, S1, S2, S3 Sensorymost of leg, foot, lower extremity joints
Motorposterior thigh muscle, leg, and foot muscles
Pudendal S2, S3, S4 SensoryPerianal skin, vulva, perineum, clitoris, urethra, vaginal vestibule
Motorexternal anal sphincter, perineal muscles, urogenital diaphragm
Estrogens undergo oxidation in the liver, and then in the slowing progression of Alzheimers disease,
conversion to glucuronide and sulphate conjugates. although in a randomized trial, estrogen administration
Significant amounts are secreted in the bile and reab- had no beneficial effect in already-established
sorbed in the bloodstream (Box 11-1). disease.
Estrogens act by multiple mechanisms in many differ- 4. On breasts and female secondary sex characteri-
ent tissues: stics: Estrogens cause breast duct growth and
1. On female genitalia: Estrogens stimulate proliferation differentiation, stimulate the growth of connective
of endometrial mucosa, facilitate the growth of the tissue, and cause pigmentation of the areolas. The
ovarian follicles, increase uterine blood flow, and body configuration, female distribution of fat in the
increase the amount of uterine muscle. breasts and buttocks, and body hair distribution are
2. On endocrine organs: Estrogens decrease FSH secre- also influenced by estrogens.
tion, increase the size of the pituitary, cause epiphyseal 5. On metabolism: Estrogens cause salt and water
closure, and increase secretion of angiotensinogen retention, which is one of the reasons women gain
and thyroid-binding globulin. weight just prior to menstruation. (Another one is
3. On central nervous system (CNS): Increase in libido is increased aldosterone levels in the luteal phase of
observed and attributed to direct effect of estrogens the cycle.) Estrogens also have a cholesterol-
on certain neurons in the hypothalamus. In neurons lowering effect.
of the hippocampus, an area involved in memory, 6. On bones: Estrogens directly inhibit the function of
estrogens increase neuronal sensitivity. Some data osteoclasts. Estrogen deficiency is known to accelerate
suggest that the decline in cognitive function in post- bone loss and increase susceptibility to fractures.
menopausal women is related to estrogen deficiency. Estrogen therapy diminishes bone loss and reduces
Reports have indicated the beneficial role of estrogens the risk of fracture in women with osteoporosis and
in those without this condition for the duration of
therapy.
7. Vascular effects: Estrogens cause short-term vasodi-
Box 11-1 Estrogens lation by increasing the formation and release of
nitric oxide and prostacyclin in endothelial
cells. They also reduce vascular smooth-muscle
Naturally occurring estrogens
tone by opening calcium channels through a
Estrone
mechanism that is dependent on cyclic guanosine
Estriol
17-Estradiol monophosphate (c-gmp).
Synthetic estrogens Synthetic estrogens are indicated for the prevention of
Tamoxifen osteoporosis and the reduction of hot flashes and other
Raloxifene symptoms of menopause. They also stimulate the growth
of endometrium and breasts, probably increasing the risk
128 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
blood gas levels, and in the number or duration of apneic lies in the clarification of the effects of estrogens on neu-
and hypopneic events. rotrophins. Neurotrophins are proteins that play an
important role in the growth of new nerve cells. This
hormonal modulation of neurotrophins increases the
PSYCHOLOGY OF THE GYNECOLOGIC connections among neuronal branches and maintains a
PATIENT complex system of communication in the brain. When
estrogen levels drop in menopause, brain cells of
There have always been numerous reports of differ- women begin to degenerate at a faster pace than those
ences between the sexes in rates of illnesses and of men. Men are relatively spared because the testos-
course of illnesses such as schizophrenia, alcoholism, terone is continuously being converted to estradiol in
mood and anxiety disorders, and Alzheimers disease. the brain (Box 11-3).
Why are women and men so different when it comes to
certain psychiatric disorders? Why are women disad-
vantaged with respect to men in Alzheimers disease, GYNECOLOGIC MALIGNANCIES
and relatively advantaged when it comes to schizophre-
nia? It is generally agreed that most of the relative dis- There were over 600,000 women diagnosed with can-
advantages that accrue to women do not take place cer in the United States in 2000. Endometrial cancer and
until after puberty. The marked sex difference in rates ovarian cancer are the fourth and fifth most common
of illness that begin with the reproductive years sug- sites of cancer in American women. The trends in gyne-
gests that that the brains hormonal environment dur- cologic cancers have changed over the past decade: the
ing adulthood may be an important point of departure incidence of invasive cervical cancer has decreased 70%,
in the search for an explanation. while preinvasive forms of cancer are increasing. Ovarian
Results from the National Comorbidity Survey have cancer incidence shows no changes since 1973, and
revealed that lifetime prevalence for major depression is endometrial cancer has decreased only very slightly.
21.3% for women compared with 12.7% for men. Women As more women survive the acute phases of gyneco-
are twice as likely as men to experience major depression logic cancer, they will be seen more often as chronic
during their lifetime and seem to be particularly vulnera- patients in a variety of medical settings, including the oper-
ble at transitions across their reproductive life cycle (pre- ating room. The care of such patients needs to take into
menstruum, puerperium, and perimenopause). consideration previous medical interventions because
With respect to female-specific mood disorders, about prior surgical history, radiation therapy, and administra-
5% of menstruating women develop premenstrual dys- tion of chemotherapeutics will affect clinical decision
phoric disorder (PMDD); 10% of childbearing women making and adequate preparation for surgery (Box 11-4).
experience postpartum onset of nonpsychotic major Chemotherapeutic agents used most commonly
depressive disorder, commonly referred to as postpartum in treatment of patients with gynecologic malignancies
depression (PPD); and 0.2% suffer a psychotic mood disor- include Cisplatin, Bleomycin, Doxorubicin, and Methot-
der (most often manic in type). Community-based survey rexate. Cisplatin is the most effective single agent against
findings suggest that perimenopause, but not post- ovarian cancer; it is also often accompanied by doxoru-
menopause, is accompanied by depressive symptoms. bicin and/or cyclophosphamide. The major dose-limiting
Although there is no sex difference in the lifetime toxicity is renal toxicity: cisplatin is a direct tubular toxin,
prevalence of schizophrenia, women develop the illness preferentially affecting the proximal straight tubule and
later, experience fewer and briefer hospitalizations, and the distal and collecting tubules. Other toxicities include
are less likely to abuse substances. Women with schizo- ototoxicity (tinnitus, high-frequency hearing loss),
phrenia enjoy better psychosocial functioning and peripheral neuropathy (in the form of stocking-glove
greater work competence than their male counterparts. distribution paresthesias), and nausea and vomiting.
In addition, women with schizophrenia perform better Preoperative evaluation as well as intraoperative manage-
on neuropsychological tests. Women suffering from
schizophrenia require lower doses of antipsychotic med-
ications than men and respond better to both psychoso- Box 11-3 Affective Disorders Highly
cial and pharmacologic treatments. Influenced by Gonadal Steroids
Women are disproportionally prone to Alzheimers
disease, even after adjustment for their longer survival: Major depression
as many as 30% to 50% of women older than 85 years Premenstrual syndrome
suffer from a dementing process. Womens cognitive Postpartum affective disorders
impairments may also be more severe than mens. Part Menopausal depression
of the increased understanding of Alzheimers disease
130 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
132
Anesthesia for Gynecologic/Oncologic Procedures 133
histamine-releasing agents should not be used in patients It is important to document the presence of neurologic
prone to bronchospasm and asthma. deficits preoperatively for subsequent comparisons.
Chemotherapeutic agents are frequently used together
with corticosteroids. A stress dose of steroids should be
Patients with Diabetes Mellitus given perioperatively to avoid Addisonian crisis in
Preoperative management of the patient with diabetes patients who have histories of such a treatment combina-
mellitus should focus on blood glucose control; avoiding tion within the past year.
hypoglycemia and ensuring long-term complications of Bleeding and fluid shifts should be anticipated for any
this disease are not adversely affected by surgery. patient undergoing a definitive operation for cancer,
Diabetes-related autonomic neuropathy may cause ortho- whether it be for potential cure, debulking, or palliation.
static hypotension, resting tachycardia, gastroparesis In that respect, the need for blood and blood products
with vomiting, diarrhea, abdominal distention, and blad- should be anticipated and the blood bank notified
der atony. accordingly.
Diabetic patients with poorly controlled insulin-
dependent diabetes will probably need to be admitted
into the hospital before the surgery and closely moni-
CLINICAL CAVEAT: PERIOPERATIVE CARE FOR
tored. The traditional approaches have been to either
THE PATIENT WITH COEXISTING DISEASE
administer one half of the dose of the intermediate-acting
insulin the morning of surgery and initiate the intra- Patient with cardiovascular diseases
venous infusion of 5% glucose to reduce the risk of hypo- Identify patients as Cardiac Risk Index Class I, II,
glycemia, or to omit the insulin the morning of surgery or III.
altogether. Continue antihypertensives.
Consider starting -adrenergic blocker, if the
patient is not already on it.
Patient with Gynecologic Malignancies Pay special attention to postoperative pain
control.
The type and extent of malignancy play a major role in Patient with respiratory diseases
determining the extent of preoperative preparation and Continue/optimize of the current treatment.
intraoperative monitoring the patient will require. The Exercise caution using respiratory center
treatment history must be thoroughly evaluated. Most depressants (e.g., opioids).
likely, these patients have had radiation therapy and Assure adequate reversal of neuromuscular
chemotherapy and, perhaps, numerous surgical proce- blockade.
dures. Depending on the type of adjunctive treatment, Patient with diabetes mellitus
Avoid hypoglycemia.
the patient may come to surgery in poor physical condi-
Assure that long-term complications of diabetes
tion from malnutrition or suffering effects of toxicity are not adversely affected by surgery.
from chemotherapy. Vascular access may be difficult to Patient with gynecologic malignancies
obtain, due to sclerosis or thrombosis of peripheral veins. Consider implications of prior treatments
Pulmonary function may be impaired by some (surgery, radiation therapy, chemotherapy).
chemotherapeutic agents, most commonly bleomycin, Assess the need for good vascular access in
while combination therapy, especially with vincristine or presence of malnutrition, dehydration, ascites,
cisplatin increases pulmonary toxicity. A preoperative and blood loss.
chest x-ray is mandatory to assess the presence of lung
injury. Severe lung disease is an indication for neuraxial
anesthesia whenever possible, or postoperative mechan-
ical ventilation may be necessary.
Patients who have been treated with cardiotoxic ADDITIONAL STUDIES
chemotherapeutic agents such as daunorubicin and dox-
orubicin are usually monitored for cardiomyopathy, Laboratory Studies
which might be of early or late onset. Although the early The laboratory investigation of a patient needs to be
form is apparent, because it is manifested by acute ST seg- limited to those diagnostic procedures that are appropri-
ment and T wave changes and dysrhythmias, the late form ate to the findings elicited during the history and physi-
is insidious in onset and usually presents as congestive cal examination. The decision to order electrolyte,
heart failure. Cardiology consultation is sought for the lat- creatinine, coagulation studies, chemistry panels, ECG,
ter to optimize the medical condition of these patients. and chest x-ray films should be based on the evaluation
Peripheral neuropathies occur commonly in patients of the patient. Patients with medical illnesses such as dia-
treated with vincristine, cyclophosphamide, and paclitaxel. betes, hypertension, and asthma need to be in optimal
Anesthesia for Gynecologic/Oncologic Procedures 135
control before surgery. Specialty consultation is generally stirrups, as this increases venous return to the heart.
necessary for patients with pulmonary or cardiac dis- Similarly, problems with hypotension on lowering legs
ease, to be sure that the best preoperative condition is postoperatively are common. When the legs are to be
achieved and that the operative risk is acceptable. lowered to the original supine position at the end of the
procedure, they should first be brought together at
the knees and ankles in the sagittal plane, and then low-
Blood Transfusion ered slowly together to the table top. This minimizes tor-
A blood sample should be sent to the blood bank well sion stress on the lumbar spine that would occur if each
in advance of the planned operative procedure so that leg were lowered independently. It also permits gradual
the blood bank will have time to overcome any difficulty accommodation to the increase in the circulatory capaci-
encountered in performing the intended crossmatch. For tance, thereby avoiding sudden hypotension. If pressure
procedures in which blood loss is not anticipated, a type on the nerve over the fibula is not prevented by adequate
and screen are sufficient. Autologous blood use should padding or positioning, common peroneal nerve injury
be encouraged if the patient is in good general health, is possible. It is manifested as an inability to dorsiflex the
whereas epoetin alfa might be considered in patients foot and a loss of sensation over the dorsum of the foot.
with low preoperative hemoglobin. Extensive clinical Hyperflexion of the hip joint can cause femoral and lat-
experience with epoetin alfa in anemic patients undergo- eral femoral cutaneous nerve palsy. Obturator and saphe-
ing major elective orthopedic surgery or those with nous nerve injury are also complications of the lithotomy
gynecologic cancers provides a strong basis for its use in position.
gynecologic surgery. Frequently, some degree of head-down tilt is added to
a lithotomy position. Depending on the degree of head
depression, the addition of tilt to the lithotomy position
Prophylactic Antibiotics combines the worst features of both the lithotomy and
The goals of antibacterial prophylaxis during gyneco- the Trendelenburg postures. The weight of abdominal
logic surgery are similar to those of prophylaxis during viscera on the diaphragm adds to whatever abdominal
intra-abdominal surgery. Prophylactic antibiotics are rec- compression is produced by the flexed thighs of an
ommended for vaginal or abdominal hysterectomy. They obese patient or of one placed in an exaggerated litho-
are not considered necessary for adnexal surgery when tomy position. Consequently, the work of spontaneous
there is no evidence of previous pelvic infection. The ventilation is increased for an anesthetized patient in a
American College of Obstetricians and Gynecologists has position that already worsens the ventilation-perfusion
recommended single-dose prophylactic protocols using ratio by gravitational accumulation of blood in the poorly
a variety of agents (penicillins, cephalosporins, and clin- ventilated lung apices. During controlled ventilation,
damycin). Patients with a valvular heart disease, history higher inspiratory pressures are needed to expand the
of endocarditis, vascular graft, or implanted devices may lung (Box 12-3).
require special antibiotic coverage (Box 12-2).
COMMON GYNECOLOGIC
PROCEDURES
INTRAOPERATIVE CONSIDERATIONS
From the anesthesiologists perspective, gynecologic
Positioning the Patient procedures can be divided into four major categories: trans-
Lithotomy position is used frequently in gynecologic vaginal, perineal, intra-abdominal, and transabdominal
surgery. The patient lies supine with each lower extrem- (laparoscopic). They are grouped according to the surgical
ity flexed at the hip and knee, and both limbs are simul- site, position, surgical technique, and equipment used.
taneously elevated and separated so that the perineum
becomes accessible to the surgeon. Hemodynamic changes
can sometimes occur on elevation of legs into the Box 12-3 Neuropathies Arising as a
Result of Poor Positioning
During Gynecologic Surgery
Box 12-2 Perioperative Need for Blood
Common peroneal nerve palsy
Type and screen Lateral femoral cutaneous nerve palsy
Encourage autologous blood donation Obturator nerve injury
Consider epoetin alfa Saphenus nerve injury
136 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
Both general and regional anesthesia can be used, in the intensive care unit (ICU). Epidural analgesia for
alone or in combination. Although vulvectomy is not par- postoperative pain management should be considered.
ticularly painful for a prolonged period postoperatively, a
continuous epidural technique allows earlier ambulation Tubal Ligation
with less sedation, especially in the elderly. In the United States, sterilization has become the most
commonly used method of contraception among mar-
Operations for Stress Urinary Incontinence ried couples. The procedure can be performed at the
Stress incontinence is a symptom that describes invol- time of cesarean delivery, shortly after delivery or induced
untary loss of urine associated with sudden cough or strain. abortion, or at a time unrelated to pregnancy. The timing
The incidence of genuine stress incontinence is 10% of tubal sterilization can influence the choice of anes-
among reproductive-aged women, but may approach thetic, the surgical approach, and the method of tubal
10% to 20% among postmenopausal patients. occlusion. Most tubal sterilizations performed after
There are currently two surgical approaches: suspen- vaginal delivery are done by minilaparotomy; those not
sion by the vaginal route and abdominal suspension pro- associated with birth are performed by laparoscopy or
cedures. Vaginal approach (Kelly urethral plication) is minilaparotomy.
often the primary surgical treatment, especially when Complications of general anesthesia are the leading
other vaginal surgery needs to be performed. Abdominal cause of death attributed to sterilization in the United
approaches (Marshall-Marchetti-Krantz and Burch) are States. The risks inherent in general anesthesia are exac-
probably more successful in long term. erbated by its use postpartum and during laparoscopy.
Patients are usually past childbearing age and need to Sterilization by minilaparotomy can be safely performed
be assessed for coexisting health problems. Both general under local anesthesia and IV sedation or regional anes-
and regional anesthesia can be used. A T10 sensory level thesia. The patient avoids the risks associated with gen-
is sufficient to provide anesthesia for procedures on the eral anesthesia, spends less time sedated or anesthetized,
uterus and bladder, whereas a T4 level is recommended if and has a more rapid recovery. Nausea and vomiting are
the peritoneum is opened. less likely to occur, and the patient is awake to report
symptoms that can indicate the occurrence of a compli-
cation (Box 12-4).
Intra-abdominal Operations
Hysterectomy (+/ Bilateral Salpingo-
Oophorectomy)
After cesarean delivery, hysterectomy is the most com- POSTOPERATIVE CONSIDERATIONS
monly performed operation in the United States. Common
indications include dysfunctional uterine bleeding, ade- Good preoperative preparation should decrease the
nomyosis, descent or prolapse of the uterus, uterine number of issues that might arise in the postanesthesia
leiomyomas, and neoplastic diseases of the uterus or adja- care unit. Nausea and pain remain the most commonly
cent pelvic organs. occurring conditions that require treatment. As discussed,
There are two surgical approaches: vaginal and extensive procedures may warrant epidural postoperative
abdominal. Often the approach is decided upon in the analgesia. Otherwise, IV patient-controlled analgesia for
OR, where a pelvic examination under anesthesia will
determine the true uterine size and the presence of
pelvic pathology.
Box 12-4 Gynecologic Surgical
General anesthesia is commonly used; however, regional
Procedures
anesthesia may be also appropriate for simple hysterec-
tomies. A T4T6 sensory level is sufficient to provide
anesthesia for procedures on the uterus. Transvaginal gynecologic surgeries
Heavy blood loss is possible. Blood and evaporative Dilation and evacuation
losses are usually greater in patients undergoing abdomi- Dilation and curettage
Laser therapy to vulva, vagina, or cervix
nal, rather than vaginal hysterectomy. Hysterectomy for
Perineal gynecologic surgeries
gynecologic tumor resection also includes oophorec- Radical vulvectomy
tomy, omentectomy, lymph node dissection, and tumor Operations for stress urinary incontinence
resection. These resections are often extensive, result in Intra-abdominal gynecologic operations
significant blood loss, and require intraoperative fluid Hysterectomy
replacement. Postoperative pain may also be significant Tubal ligation
due to the extent of the surgery. These patients may Abdominal debulking
require short-term postoperative ventilation and/or time
138 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
in-patients or oral opioids +/ NSAIDs or COX-2 inhibitors Maranets I, Kain ZN: Preoperative anxiety and intraoperative
for out-patients provide good pain control. anesthetic requirements. Anesth Analg 89:13461351, 1999.
Martin J: Patient Positioning. In Barash P, Cullen B, Stoelting R
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American College of Physicians: Guidelines for assessing and
McFarland JG: Perioperative blood transfusions. Chest 115:
managing the perioperative risk from coronary artery disease
113S121S, 1999.
associated with major noncardiac surgery. Ann Internal Med
127(4):309312, 1997. Meyer R: Rofecoxib reduces perioperative morphine consump-
tion for abdominal hysterectomy and laparoscopic gastric
ASHP: Therapeutic guidelines on antimicrobial prophylaxis in
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Papadimitriou L, Livanios S, Katsaros G, et al: Prevention of
Bucklin BA, Smith CV: Postpartum tubal ligation: Safety, tim-
postoperative nausea and vomiting after laparoscopic gyne-
ing, and other implications for anesthesia. Anesth Analg
cologic surgery. Combined antiemetic treatment with tro-
89:12691274, 1999.
pisetron and metoclopramide alone. Eur J Anesth 18(9):
Doyle RL: Assessing and modifying the risk of postoperative 615619, 2001.
pulmonary complications. Chest 115:77S81S, 1999.
Parker BM, Tetzlaff JE, Litaker DL, Maurer WG: Redefining the
Fahy BG, Barnas GM, Nagle SE, Flowers JL: Effects of preoperative evaluation process and the role of the anesthe-
Trendelenburg and reverse Trendelenburg postures on lung siologist. J Clin Anesth 12(50):350356, 2000.
and chest wall mechanics. J Clin Anesth 8(3):236244, 1996.
Rock JA, Jones HA (eds): Te Lindes Operative Gynecology, 9th
Garfield JM, Muto MG, Bizzari-Schmid M: Anesthesia for edition. Philadelphia, Lippincott, Williams and Wilkins, 2003.
Gynecologic Surgery. Principles and Practice of Anesthesiology.
Sawaya GF, Grady D, Kerlikowske K, Grimes DA: Antibiotics
New York, Mosby, 1993.
at the time of induced abortion: The case for universal pro-
Goldman L: Cardiac risk in noncardiac surgery: An update. phylaxis based on a metaanalysis. Obstet Gyn 87(5 Pt 2):
Anesth Analg 80(4):810820, 1995. 884890, 1996.
Guaschino S, De Santo D, De Seta F: New perspectives in anti- Smetana GW: Preoperative pulmonary evaluation. N Engl J Med
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J Hospital Infect 50(Suppl A):S13S16, 2002.
Southorn P: Preoperative management of the medically at-risk
Halliwill JR, Hewitt SA, Joyner MJ, Warner MA: Effect of vari- patient. Clin Obstet Gyn 2002; 45(2): 449468
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Speir BR, Freeman MG: Psychological Aspects of Pelvic
Anesthesiology 89(6):13731376, 1998.
Surgery. In Rock JA, Jones HA (eds): Te Lindes Operative
Hampl KF, Heinzman-Wiedmer S, Luginbuehl I, et al: Transient Gynecology, 9th edition. Philadelphia, Lippincott, Williams
neurologic symptoms after spinal anesthesia: A lower inci- and Wilkins, 2003.
dence with prilocaine and bupivacaine than with lidocaine.
Stone SG, Foex P, Sear JW, et al: Risk of myocardial ischemia
Anesthesiology 88(3):629633, 1998.
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Hampl KF, Schneider MC, Pargger H, et al: A similar incidence patients. Br J Anaesth 61(6):675679, 1988.
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Stovall TG: Clinical experience with epoetin alfa in the manage-
with 2% and 5% lidocaine. Anesth Analg 83:10511054,1996.
ment of hemoglobin levels in orthopedic surgery and cancer.
Hampl KF, Schneider MC, Ummenhofer W, Drewe J: Transient Implications for use in gynecologic surgery. J Reprod Med
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Thomas R, Jones N: Prospective randomized, double-blind
Harrison BA, Burkle CM: Cardiorespiratory emergencies asso- comparative study of dexamethasone, ondansetron, and
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Anesthesia for Gynecologic/Oncologic Procedures 139
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Anesthesiology 92(4):11891191, 2000. neuropathies associated with lithotomy positions. Anesthesi-
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1987.
13
CHAPTER Management
of Pelvic Pain
MIRJANA LOVRINCEVIC
HISTORY
ETIOLOGY
History-taking is the first and probably the most
Chronic pelvic pain can be classified as the following: important part of the evaluation of a patient with pelvic
1. Pain arising from the reproductive tract pain. Patients are usually asked to complete a standardized
2. Pain arising from other organ systems medical and pain questionnaire that is followed by a
3. Nonorganic disease, but evidence of a psychiatric structured interview. Particular attention is paid to associa-
disease tion of symptoms with menstrual cycle because some of
4. No evidence of organic or psychiatric disease these occur only with menses, others increase with
menses, and still others are not related to menses at all.
Chronic pelvic pain arising from the reproductive Patients are also asked to point to all areas of pain: it is not
tract: uncommon to have patients point to their legs, flank, and
Endometriosis upper abdomen. Irritable bowel syndrome, appendicitis,
Pelvic adhesions pyelonephritis, cholecystitis, ulcers, and other diseases
Pelvic venous congestion not originating from the pelvic area may be coincidentally
Cyclic pain or indirectly related to cyclic hormonal changes. Screeni-
Cancer pain ng for dysmotility disorders of the bowel should be also
included. Associated symptoms are of particular impor-
Chronic pelvic pain arising from the other organ tance because they are dependent on the primary cause
systems: of the pain or the involvement of adjacent structures.
Irritable bowel syndrome Special attention should be paid to a sexual history,
Recurrent cystitis and interstitial cystitis including history of physical and sexual abuse. Standard-
Abdominal myofascial pain ized screening psychometric measures, such as West
140
Management of Pelvic Pain 141
Haven-Yale Multidimensional Pain Inventory (WHYMPI), Endometriosis-associated pelvic pain commonly per-
a marital adjustment scale (Locke-Wallace), and the Beck sists throughout the reproductive years, and a clinical
Depression Inventory can prove to be very useful as well. diagnosis may be made on the basis of a history with the
triad of symptoms: dysmenorrhea, dyspareunia, and abnor-
mal uterine bleeding, as well as classic physical findings
PHYSICAL ASSESSMENT of uterosacral nodularity. The American Society for
Reproductive Medicine is trying to adjust the classifica-
Physical assessment starts with a standardized exam tion of endometriosis so that it is able to predict outcome
and narrows down to particular areas of tenderness. with respect to pregnancy, as well as to aid in the man-
Reproducing trigonal or urethral tenderness usually agement of chronic pelvic pain.
points toward diagnosis of urethral syndrome or intersti-
tial cystitis. CURRENT CONTROVERSY: CONSERVATIVE
If the pain is limited to a localized area and is repro- VERSUS INVASIVE TREATMENT FOR
duced and exacerbated by direct palpation of these areas ENDOMETRIOSIS
of maximal tenderness, myofascial pain is suspected.
Recent studies have demonstrated that surgical
Injections at abdominal wall and pelvic floor muscle trig-
therapy offers no better pain control than medical
ger points seem to be very successful if the patient is therapy with gonadotropin-releasing hormone agonist.
cooperative in pinpointing the painful areas. Recurrence of symptoms after surgical intervention
In young patients, cyclic pelvic pain and dysmenor- occurs in 44% of patients within 1 year of treatment.
rhea are common with endometriosis. Focal tenderness Repeated operations are associated with a progressive
correlates with deep fibrotic endometriosis or other reduction in the chance of permanent success.
fibrotic pathology. Studies showed that diagnosing deep Gonadotropin-releasing hormone analogues have
disease could be facilitated by examination during been associated with significant pain control.
menses. Downside? Significant osteoporosis.
Various combinations of estrogen and progestin
were found to be effective in reducing chronic pain
of endometriosis. Contraindications are the same as
DIAGNOSTIC INVESTIGATIONS
for oral contraceptives, in general.
Androgens produce atrophy of the endometriotic
In context of a multidisciplinary approach to the patient implants and control of pain. Virilization, however,
with chronic pelvic pain, systematic diagnostic methods is a very undesirable side effect.
are used. Laboratory examination should include a com-
plete blood count, sedimentation rate, urinalysis, cervical
smear and cultures, cytology, CA-125 level, and radi- Multiple attempts have been made to correlate stage of
ographic studies, such as ultrasonography, hysterosalpin- disease and severity of pain. Important variables include
gography, or contrast radiography of the gastrointestinal depth of invasion, histology, location, and preoperative
tract. The results are integrated with the information physical findings and investigations, and although the
obtained from the history and physical examination. endometriosis stage is not directly related to the degree of
Additional tests might be performed when specific pathol- pain, it is related to the persistence of pelvic pain.
ogy is suspected: cystoscopy with hydrodistention and Whereas in the past laparoscopy was commonly used
bladder biopsy, and intravesical potassium sensitivity for for the diagnosis and treatment of women with
interstitial cystitis; pelvic phlebography to document the endometriosis and pelvic pain, recent studies have demon-
presence of venous congestion of the pelvis; microla- strated that surgical therapy offers no better results in
paroscopy under local anesthesia and conscious pain map- terms of pain relief than medical therapy with a
ping for various etiologies of pelvic pain as well as a gonadotropin-releasing hormone agonist. In fact, from
preoperative assessment for patients with central pelvic the results of the randomized controlled trials, recur-
pain considering either laparoscopic uterosacral nerve rence of symptoms after surgical intervention occurs in
ablation or presacral neurectomy; classic laparoscopy 44% of patients within 1 year of treatment by an experi-
and/or laparotomy as the ultimate diagnostic method. enced surgeon. Repeated operations are associated with
a progressive reduction in the chance of permanent suc-
cess and are not always feasible.
Chronic Pelvic Pain Arising from Gonadotropin-releasing hormone analogs (e.g.,
the Reproductive Tract leuprorelin) are the newest medications used for the
Endometriosis refers to the presence of extrauterine treatment of endometriosis and have been associated
endometrial tissue and the clinical sequelae produced by with significant control of pain. Significant osteoporosis,
its normal function in an abnormal site. however, can occur when used for more than 6 months.
142 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
Various combinations of added estrogen and progestin Meta-analyses reviewing controlled trials of treatment
have been used to decrease osteoporosis. in patients suffering from pelvic congestion syndrome
Gestagens alone, such as lynestrenol, might be used showed that progestogen was associated with a reduc-
as second-line drugs for long-term and continuous treat- tion of pain during treatment. Counseling supported by
ment in the management of endometriosis. A low daily ultrasound scanning was associated with reduced pain
oral dose of cyproterone acetate and a continuous and improvement in mood. Adhesiolysis was not associ-
monophasic oral contraceptive containing ethinyl estra- ated with an improved outcome apart from where adhe-
diol and desogestrel were found to be similarly effective sions were severe.
in reducing chronic pelvic pain in one of the studies. Embolization of the ovarian veins has emerged as an
Subcutaneous implantation of buserelin acetate was attractive modality lately: transcatheter embolization of
also found to be effective, although adverse effects were the ovarian veins is a safe and feasible technique leading
significant. to complete relief of symptoms in more than half of
The observation that hyperandrogenic states induce cases. It should be emphasized, though, that careful
atrophy of the endometrium has led to the use of andro- selection of patients and use of appropriate angiographic
gens (e.g., danazol) in the treatment of endometriosis. and technical skills by the interventional radiologist are
The efficacy of danazol is based on its ability to produce a requisite for the success of this therapeutic alternative.
high androgen/low estrogen environment that results in Cyclic pain, or primary dysmenorrhea, is colicky, low
the atrophy of endometriotic implants and control of pain. abdominal pain during menstruation that occurs pre-
dominantly in young women. As a rule, it is not associ-
CURRENT CONTROVERSY: TREATMENT ated with any other diseases, such as endometriosis.
OF PELVIC ADHESIONS Increased uterine tone and high-amplitude contractions
during menstruation result in decreased uterine blood
Laparoscopic adhesiolysis seems to be effective thera- flow, all due to increased endometrial prostaglandin pro-
peutic measure according to numerous retrospective duction. Considering high prevalence rates (43% to 90%
studies, whereas some prospective studies showed no
in some studies), dysmenorrhea may not even come to
benefit, except for the small subset of patients with
adhesions involving the bowel.
medical attention, although it frequently causes absen-
teeism and decreased quality of life.
The risk factors for dysmenorrhea are early age at
Pelvic adhesions are bands of fibrous tissue that join menarche, long menstrual periods, smoking, alcohol
abdominal organs to each other or the abdominal wall. intake, and weight above the 90th percentile.
Adhesions develop rapidly after damage to the peri- Considering the relation of this condition to hormonal
toneum during surgery, infection, trauma, or irradiation. changes during menstrual cycle, and increased prostag-
Until recently, it was thought that the pain secondary to landin production, it is not surprising that nonsteroidal
adhesions occurs because of restricted organ mobility anti-inflammatory drugs and combined oral contraceptives
and stimulation of stretch receptors. However, it was are the most commonly used treatments. Calcium antago-
shown that adhesions contain sensory nerve fibers capa- nists, glyceryl trinitrate, transcutaneous electric nerve
ble of producing pain stimuli independently. stimulation, acupuncture, and herbal remedies have also
Laparoscopic adhesiolysis seems to be an effective been reported to provide pain relief, although their long-
therapeutic measure to relieve chronic pelvic pain term effectiveness is not known.
according to numerous retrospective studies, whereas Cancer pain requires special attention, because it is
one prospective randomized trial showed no benefit, not only a manifestation of a serious disease with often-
except for the small subset of patients with dense adhe- poor prognosis, but it is also associated with negative
sions involving the bowel. expectations, depressed mood states, and a decrease in a
Pelvic venous congestion in association with chronic patients quality of life. Patients with gynecologic malig-
pelvic pain was first time described in the late 1950s. nancies may experience chronic pain as a result of either
The primary problem is retrograde flow in incompetent the disease process itself or cancer treatment.
ovarian and pelvic veins, confirmed by injecting contrast Pelvic pain has been reported frequently by women
into the ovarian and/or internal iliac veins. Patients usu- with gynecologic cancer. It is usually described as a vague,
ally complain of pain in the pelvic area when standing poorly localized sensation of fullness, pressure, and dis-
or in the upright position, during or after intercourse, comfort, although intermittent shooting pains or a burn-
and in association with varices in the thighs, buttocks, ing sensation deep in the perineum are reported as well.
perineum, vulva, or vagina. Although the transuterine The Cancer Relief Program of the World Health
venogram supports the diagnosis, the degree of organic Organization (WHO) developed the analgesic ladder that
disease is minimally related to pain and functional has become a widely accepted method of drug selection
impairment. (Fig. 13-1). Although it is not strictly followed especially
Management of Pelvic Pain 143
anesthetic and/or clonidine act synergistically to produce Abdominal myofascial pain is a common physical
effective analgesia while decreasing the side effects of sequela to psychological stress as well as muscle tension.
individual drugs by allowing lower doses of each. Very This is noteworthy because many patients are being
infrequently, patients will not achieve adequate pain con- treated for myofascial trigger points or post-traumatic
trol with triple intrathecal therapy. In the future, the use neuromas, which are obviously sensitive to muscle
of adenosine, aspirin, and ziconotide may become a viable tension.
alternative for patients with complex pain problems.
lack of cortisol in traumatized or chronically stressed Kaplan B, Rabinerson D, Lurie S, et al: Clinical evaluation of a
individuals might promote an increased vulnerability new model of a transcutaneous electrical nerve stimulation
for chronic pain syndromes, as well as for chronic fatigue device for the management of primary dysmenorrhoea.
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Psychological treatment modalities are tailored to the Koninckx PR, Meuleman C, Oosterlynck D, Cornillie FJ: Diagnosis
individual needs of the patient and begin with the most of deep endometriosis by clinical examination during men-
basic interventions, such as behavioral therapy, and move struation and plasma CA-125 concentrations. Fertil Steril
65:280287, 1996.
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Lampe A, Solder E, Ennemoser A, et al: Chronic pelvic pain and
Complexity of pelvic pain requires a multidisciplinary
previous sexual abuse. Obstet Gynecol 96(6):929933, 2000.
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A questionnaire-based analysis of practice patterns. Urology
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54(1):3743, 1999.
are necessary for the understanding of this common prob-
lem that strikes women of all ages much too often. Lentz G, Bavendam T, Stenchever MA, et al: Hormonal manipu-
lation in women with chronic, cyclic irritable bladder symptoms
and pelvic pain. Am J Obstet Gynecol 186(6): 12681273, 2002.
Ludwig H: Dysmenorrhea. Therapeutische Umschau 53(6):
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Aboseif S, Tamaddon K, Chalfin S, et al: Sacral neuromodula- Maleux G, Stockx L, Wilms G, Marchal G: Ovarian vein emboliza-
tion as an effective treatment for refractory pelvic floor dys- tion for the treatment of pelvic congestion syndrome: Long-
function. Urology 60(1):5256, 2002. term technical and clinical results. J Vascular Intervent Radiol
Choktanasiri W, Rojanasakul A: Buserelin acetate implants in 11(7):859864, 2000.
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Appendix 1:
Factors That May Place
a Woman at Increased
Risk from Anesthesia
147
Appendix 2:
Guidelines for Regional
Anesthesia in
Obstetrics
(Approved by House of Delegates on October 12, Physicians should be approved through the institu-
1988, and last amended on October 18, 2000. Reprinted tional credentialing process to initiate and direct the
from American Society of Anesthesiologists, Park Ridge, maintenance of obstetric anesthesia and to manage pro-
Illinois.) cedurally related complications.
These guidelines apply to the use of regional anes-
thesia or analgesia in which local anesthetics are admin-
istered to the parturient during labor and delivery. They GUIDELINE III
are intended to encourage quality patient care but can-
not guarantee any specific patient outcome. Because REGIONAL ANESTHESIA SHOULD NOT BE ADMINIS-
the availability of anesthesia resources may vary, mem- TERED UNTIL: (1) THE PATIENT HAS BEEN EXAMINED
bers are responsible for interpreting and establishing BY A QUALIFIED INDIVIDUAL2 AND (2) A PHYSICIAN
the guidelines for their own institutions and practices. WITH OBSTETRIC PRIVILEGES TO PERFORM OPERA-
These guidelines are subject to revision from time to TIVE VAGINAL OR CESAREAN DELIVERY, WHO HAS
time as warranted by the evolution of technology and KNOWLEDGE OF THE MATERNAL AND FETAL STATUS
practice. AND THE PROGRESS OF LABOR AND WHO APPROVES
THE INITIATION OF LABOR ANESTHESIA, IS READILY
AVAILABLE TO SUPERVISE THE LABOR AND MANAGE
ANY OBSTETRIC COMPLICATIONS THAT MAY ARISE.
GUIDELINE I Under circumstances defined by department protocol,
qualified personnel may perform the initial pelvic examina-
REGIONAL ANESTHESIA SHOULD BE INITIATED AND tion. The physician responsible for the patients obstetric
MAINTAINED ONLY IN LOCATIONS IN WHICH APPRO- care should be informed of her status so that a decision can
PRIATE RESUSCITATION EQUIPMENT AND DRUGS ARE be made regarding present risk and further management.2
IMMEDIATELY AVAILABLE TO MANAGE PROCEDUR-
ALLY RELATED PROBLEMS.
Resuscitation equipment should include, but is not
GUIDELINE IV
limited to: sources of oxygen and suction, equipment
to maintain an airway and perform endotracheal intuba-
AN INTRAVENOUS INFUSION SHOULD BE ESTAB-
tion, a means to provide positive pressure ventilation,
LISHED BEFORE THE INITIATION OF REGIONAL-
and drugs and equipment for cardiopulmonary resusci-
ANESTHESIA AND MAINTAINED THROUGHOUT THE
tation.
DURATION OF THE REGIONAL ANESTHETIC.
GUIDELINE II GUIDELINE V
REGIONAL ANESTHESIA SHOULD BE INITIATED BY A REGIONAL ANESTHESIA FOR LABOR AND/OR VAGI-
PHYSICIAN WITH APPROPRIATE PRIVILEGES AND NAL DELIVERY REQUIRES THAT THE PARTURIENTS
MAINTAINED BY OR UNDER THE MEDICAL DIREC- VITAL SIGNS AND THE FETAL HEART RATE BE MONI-
TION1 OF SUCH AN INDIVIDUAL. TORED AND DOCUMENTED BY A QUALIFIED INDIVID-
148
Appendix 2: Guidelines for Regional Anesthesia in Obstetrics 149
(Approved by the ASA House of Delegates on October IV. Appointment of a qualified anesthesiologist
18, 2000. Reprinted from American Society of Anesthesio- to be responsible for all anesthetics adminis-
logists, Park Ridge, Illinois.) tered. There are obstetric units where obstetri-
This joint statement from the American Society of cians or obstetrician-supervised nurse anesthetists
Anesthesiologists (ASA) and the American College of administer anesthetics. The administration of gen-
Obstetricians and Gynecologists (ACOG) has been eral or regional anesthesia requires both medical
designed to address issues of concern to both special- judgment and technical skills. Thus, a physician
ties. Good obstetric care requires the availability of with privileges in anesthesiology should be readily
qualified personnel and equipment to administer gen- available.
eral or regional anesthesia, both electively and emer- Persons administering or supervising obstetric anes-
gently. The extent and degree to which anesthesia thesia should be qualified to manage the infrequent but
services are available vary widely among hospitals. occasionally life-threatening complications of major
However, for any hospital providing obstetric care, cer- regional anesthesia such as respiratory and cardiovascu-
tain optimal anesthesia goals should be sought. These lar failure, toxic local anesthetic convulsions, or vomit-
include: ing and aspiration. Mastering and retaining the skills and
I. Availability of a licensed practitioner who is knowledge necessary to manage these complications
credentialed to administer an appropriate anes- require adequate training and frequent application.
thetic whenever necessary. For many women, To ensure the safest and most effective anesthesia for
regional anesthesia (epidural, spinal, or combined obstetric patients, the director of anesthesia services,
spinal-epidural) will be the most appropriate with the approval of the medical staff, should develop
anesthetic. and enforce written policies regarding provision of
II. Availability of a licensed practitioner who is obstetric anesthesia. These include:
credentialed to maintain support of vital functions I. Availability of a qualified physician with obstetric
in any obstetric emergency. privileges to perform operative vaginal or cesarean
III. Availability of anesthesia and surgical personnel delivery during administration of anesthesia.
to permit the start of a cesarean delivery within Regional and/or general anesthesia should not be
30 minutes of the decision to perform the administered until the patient has been examined
procedure; in cases of VBAC, appropriate facilities and the fetal status and progress of labor evaluated
and personnel, including obstetric anesthesia, by a qualified individual. A physician with obstetric
nursing personnel, and a physician capable of privileges who has knowledge of the maternal and
monitoring labor and performing cesarean delivery, fetal status and the progress of labor, and who
immediately available during active labor to approves the initiation of labor anesthesia, should
perform emergency cesarean delivery.1 The be readily available to deal with any obstetric
definition of immediate availability of personnel and complications that may arise.
facilities remains a local decision, based on each II. Availability of equipment, facilities, and support
institutions available resources and geographic personnel equal to that provided in the surgical suite.
location. This should include the availability of a properly
150
Appendix 3: Optimal Goals for Anesthesia Care in Obstetrics 151
equipped and staffed recovery room capable of The availability of the appropriate personnel to assist
receiving and caring for all patients recovering in the management of a variety of obstetric problems is a
from major regional or general anesthesia. Birthing necessary feature of good obstetric care. The presence
facilities, when used for analgesia or anesthesia, must of a pediatrician or other trained physician at a high-risk
be appropriately equipped to provide safe anesthetic cesarean delivery to care for the newborn or the avail-
care during labor and delivery or postanesthesia ability of an anesthesiologist during active labor and
recovery care. delivery when vaginal birth after cesarean delivery
Personnel other than the surgical team should be (VBAC) is attempted, and at a breech or twin delivery are
immediately available to assume responsibility for resusci- examples. Frequently, these professionals spend a con-
tation of the depressed newborn. The surgeon and anes- siderable amount of time standing by for the possibility
thesiologist are responsible for the mother and may not be that their services may be needed emergently but may
able to leave her care for the newborn, even when ultimately not be required to perform the tasks for which
a regional anesthetic is functioning adequately. Individuals they are present. Reasonable compensation for these
qualified to perform neonatal resuscitation should demon- standby services is justifiable and necessary.
strate: A variety of other mechanisms have been suggested to
A. Proficiency in rapid and accurate evaluation of the increase the availability and quality of anesthesia services
newborn condition including Apgar scoring. in obstetrics. Improved hospital design to place labor
B. Knowledge of the pathogenesis of a depressed and delivery suites closer to the operating rooms would
newborn (acidosis, drugs, hypovolemia, trauma, allow for more efficient supervision of nurse anes-
anomalies, and infection), as well as specific indi- thetists. Anesthesia equipment in the labor and delivery
cations for resuscitation. area must be comparable to that in the operating room.
C. Proficiency in newborn airway management, Finally, good interpersonal relations between obstetri-
laryngoscopy, endotracheal intubations, suctioning cians and anesthesiologists are important. Joint meetings
of airways, artificial ventilation, cardiac massage, between the two departments should be encouraged.
and maintenance of thermal stability. Anesthesiologists should recognize the special needs and
In larger maternity units and those functioning as concerns of the obstetrician, and obstetricians should
high-risk centers, 24-hour in-house anesthesia, obstetric, recognize the anesthesiologist as a consultant in the man-
and neonatal specialists are usually necessary. Preferably, agement of pain and life-support measures. Both should
the obstetric anesthesia services should be directed by recognize the need to provide high-quality care for all
an anesthesiologist with special training or experience in patients.
obstetric anesthesia. These units will also frequently
require the availability of more sophisticated monitoring
REFERENCE
equipment and specially trained nursing personnel.
A survey jointly sponsored by the ASA and ACOG 1. American College of Obstetricians and Gynecologists.
found that many hospitals in the United States have Vaginal birth after previous cesarean delivery. ACOG Practice
not yet achieved the above goals. Deficiencies were most Bulletin. Washington, DC, ACOG, 1999.
evident in smaller delivery units. Some small delivery
units are necessary because of geographic considera-
tions. Currently, approximately 50% of hospitals provid- SUGGESTED READING
ing obstetric care have fewer than 500 deliveries per Committee on Perinatal Health, Toward Improving the Outcome
year. Providing comprehensive care for obstetric patients of Pregnancy: The 90s and Beyond. White Plains, NY, March
in these small units is extremely inefficient, not cost- of Dimes Birth Defects Foundation, 1993.
effective, and frequently impossible. Thus, the following
recommendations are made:
1. Whenever possible, small units should consolidate.
2. When geographic factors require the existence of
smaller units, these units should be part of a well-
established regional perinatal system.
Appendix 4:
Standards for
Postanesthesia Care
(Approved by House of Delegates on October 12, 3. The design, equipment, and staffing of the PACU
1988, and last amended on October 27, 2004. Reprinted shall meet requirements of the facilitys accrediting
from American Society of Anesthesiologists, Park Ridge, and licensing bodies.
Illinois.)
These standards apply to postanesthesia care in all
locations. These standards may be exceeded based on the STANDARD II
judgment of the responsible anesthesiologist. They are
intended to encourage quality patient care but cannot A PATIENT TRANSPORTED TO THE PACU SHALL BE
guarantee any specific patient outcome. They are subject ACCOMPANIED BY A MEMBER OF THE ANESTHESIA CARE
to revision from time to time as warranted by the evolu- TEAM WHO IS KNOWLEDGEABLE ABOUT THE PATIENTS
tion of technology and practice. Under extenuating cir- CONDITION. THE PATIENT SHALL BE CONTINUALLY
cumstances, the responsible anesthesiologist may waive EVALUATED AND TREATED DURING TRANSPORT WITH
the requirements marked with an asterisk ( *); it is rec- MONITORING AND SUPPORT APPROPRIATE TO THE
ommended that when this is done, it should be so PATIENTS CONDITION.
stated (including the reasons) in a note in the patients
medical record.
STANDARD III
152
Appendix 4: Standards of Postanesthesia Care 153
(Approved by House of Delegates on October 12, 3. Personal participation in the technical aspects of the
1983, and last amended on October 16, 2002. Reprinted regional anesthetic when appropriate
from American Society of Anesthesiologists, Park Ridge, 4. Following the course of the anesthetic
Illinois.) 5. Remaining physically available for the immediate
While scope of practice is a matter to be decided by diagnosis and treatment of emergencies
appropriate licensing and credentialing authorities, the 6. Providing indicated postanesthesia care
American Society of Anesthesiologists, as an organization The technical requirements for regional anesthesia
of physicians dedicated to enhancing the safety and qual- will vary with the procedure to be performed.
ity of anesthesia care, believes it is appropriate to state The decision as to the most appropriate anesthetic
its views concerning the provision of regional anesthe- technique for a particular patient is a judgment of med-
sia. These views are founded on the premise that patient ical practice that must consider all patient factors, proce-
safety is the most important goal in the provision of anes- dure requirements, risks and benefits, consent issues,
thesia care. surgeon preferences, and competencies of the practition-
Anesthesiology, in all of its forms, including regional ers involved. The decision to perform a specific regional
anesthesia, is the practice of medicine. Regional anesthe- anesthetic technique is best made by a physician trained
sia involves diagnostic assessment, the consideration of in the medical specialty of anesthesiology. The decision
indications and contraindications, the prescription of to interrupt or abort a technically difficult procedure,
drugs, and the institution of corrective measures and recognition of complications and changing medical con-
treatment in response to complications. Therefore, the ditions, and provision of appropriate postprocedure care
successful performance of regional anesthesia requires are the duties of a physician. Regional anesthetic tech-
medical as well as technical expertise. The medical com- niques are best performed by an anesthesiologist who
ponent generally comprises the elements of medical possesses the competence and skills necessary for safe
direction and includes the following: and effective performance.
1. Preanesthetic evaluation of the patient
2. Prescription of the anesthetic plan
154
Appendix 6:
Summary of Practice
Guidelines for
Obstetric Anesthesia
Guidelines are meant to provide basic recommenda- concentrations while still providing effective
tions for clinical care to assist the anesthesiologist in analgesia without motor block.
making patient care decisions. The Guidelines summa- 2. Spinal opioids may be used for time-limited labor
rized below are intended for peripartum patients.1 analgesia.
Preanesthetic Assessment 3. Combined spinal-epidural techniques may be used
1. A focused history and physical should be performed to provide rapid, effective analgesia.
by the anesthesiologist prior to providing anesthesia 4. MAC for complicated vaginal delivery may reduce
care. This should include a history, which reviews complications and should be available upon
issues related to the pregnancy and a limited request.
physical exam including blood pressure, airway Retained Placenta
assessment, and back exam if regional anesthesia is 1. Regional or general anesthesia or sedation/analgesia
considered. may be used for removal of retained placenta.
2. An intrapartum platelet count may be beneficial in 2. Low-dose nitroglycerine is an effective alternative
reducing complications in patients with pregnancy- for uterine relaxation during removal of retained
induced hypertension or signs of coagulopathy. placenta.
3. A blood type and screen or cross match should be Cesarean Delivery
individualized based on assessment of risk 1. Choice of anesthetic should be individualized.
complications. Regional anesthesia is associated with fewer maternal
4. FHR should be monitored and documented before and and neonatal complications when compared with
after placement of regional analgesia for labor. general anesthesia.
Oral Intake Postpartum Tubal Ligation (PPTL)
1. Clear liquids may be allowed for uncomplicated Timing and anesthetic choice for PPTL should be indi-
laboring patients. vidualized after evaluation of the patient. PPTL may be
2. Solid food should be avoided in labor. safely performed within 8 hours of delivery in many
3. Fasting in patients for elective cesarean delivery patients.
should be consistent with policies for nonobstetric Management of Complications
elective surgery patients. 1. The institution should have resources available to
Intrapartum Care manage hemorrhage. These included large-bore IV
Choice of analgesic techniques should consider patient catheters, fluid warmers, forced-air body warming,
preference and practitioner preferences. Resources for blood bank resources, and rapid IV infusion devices.
treatment of complications should be available. 2. Resources for airway emergencies should include
1. Epidural analgesia is best with low concentrations basic airway equipment (laryngoscope, ETT, LMA,
of local anesthetic and opioid. Continuous infusion oxygen, suction, bag and mask) as well as a portable
techniques may allow lower analgesia/opioid difficult airway cart.
155
156 OBSTETRIC AND GYNECOLOGIC ANESTHESIA: THE REQUISITES IN ANESTHESIOLOGY
(Approved by the House of Delegates on October 13, for regional analgesia/anesthesia during labor unless a
1999. Reprinted from American Society of Anesthesio- physician has documented the presence of a medical
logists, Park Ridge, Illinois.) indication for regional analgesia/anesthesia. Of the vari-
Labor results in severe pain for many women. There is ous pharmacologic methods used for pain relief during
no circumstance where it is considered acceptable for a labor and delivery, regional analgesia techniques, epidural,
person to experience untreated severe pain, amenable to spinal, and combined spinal-epidural are the most flexi-
safe intervention, while under a physicians care. In the ble, effective, and least depressing to the central nervous
absence of a medical contraindication, maternal request system, allowing for an alert, participating mother and
is a sufficient medical indication for pain relief during alert neonate. It is the position of ACOG and ASA that
labor. Pain management should be provided whenever third-party payers who provide reimbursement for obstet-
medically indicated. ric services should not deny reimbursement for regional
Nonetheless, ASA and ACOG have received reports analgesia/anesthesia because of an absence of other
that some third-party payers have denied reimbursement medical indications.
157
Index
Note: Page numbers followed by f refer to figures; those followed by t refer to tables, and those followed by b refer to boxes.
A Analgesic ladder, pelvic pain management Anesthesia, for cesarean delivery, 5758
and, 142143, 143f (Continued)
Abnormal presentation, in high-risk Anesthesia, epidural, in morbid obesity in, spinal injection after epidural injection in,
obstetric patients, 9194, 92f 101102, 103 65, 66f
Abortion, spontaneous, in Anesthesia, for cesarean delivery, 5758 succinylcholine in, 71
anesthesia/nonobstetric surgery, 22 anesthesia maintenance in, 70 technique choice in, 5859, 60f
Abruptio placenta, in high-risk obstetric anesthetic agents in, 7071 thiopental in, 70
patients, 8586, 85b volatile, 7071 ultrasound in, 62
Adhesions. See Pelvic adhesions awareness prevention in, 69 vecuronium/atracurium in, 71
American College of Obstetricians and bupivacaine in, 63, 6465, 64t Anesthesia, for fetal surgery
Gynecologists (ACOG) for cesarean delivery, 6267, 63f, 64t, 66f considerations for, 26
complications/risk management and, 121 combined spinal-epidural anesthesia endoscopy in, 2728, 27t
obstetric anesthesiology services and, 114, in, 65 EXIT procedures and, 25, 26t, 28
115, 116 difficult airway algorithm in, 67, 68f fetal defects and, 25, 26t, 27t
American Society of Anesthesiologists (ASA), ECG in, 62 fetoscopy in, 25, 2728, 27t
obstetric anesthesiology services and, epidural anesthesia in, 6465 maternal-fetal indications in, 2526,
114, 115 etomidate in, 70 26t, 27t
Analgesia, for labor failed intubation in, 69 open fetal surgery in, 2627, 27t
morbid obesity and, 101102 fluid preload in, 6162 tocolytic agents in, 27t
pre-eclampsia and, 8283 general anesthesia in, 6770, 68f Anesthesia, for gynecologic/oncologic
Analgesia, for labor/delivery, 2930 induction in, 67 procedures
bupivacaine in, 33t, 34t high spinal anesthesia in, 66 additional studies in, 134135
caudal anesthesia and, 36 induction agents in, 70 blood transfusion in, 135
epidural anesthesia and, 3136, 32f, 33t, 34t ketamine in, 70 prophylactic antibiotics in, 135, 135b
epidural infusions in, 33t lidocaine in, 6465 coexisting diseases and, 133134
epinephrine in, 36 local anesthetic toxicity in, 66 Cardiac Risk Index and, 133
fentanyl in, 33, 33t, 34t, 35b MAC in, 69, 7071 cardiovascular disease and, 133
intrathecal technique in, 34, 34t magnesium sulfate interactions in, 71 diabetes mellitus and, 134
lidocaine in, 34t Mallampati classification in, 58, 58f gynecologic malignancies and, 134
lumbar sympathetic block in, 37 maternal position in, 62 respiratory disease and, 133134
meperidine in, 34t maternal ventilation in, 6970 intra-abdominal surgery in
neuraxial techniques in, 3136, 32f, 33t, 34t midazolam in, 70 hysterectomy in, 137
nonpharmacologic techniques in, 3031 monitoring in, 62 tubal ligation in, 137, 137b
opioids in, 30, 31, 31t in morbid obesity, 102105 intraoperative considerations in, patient
pain transmission and, 30 neuromuscular blockers in, 71 positioning in, 135, 135b
paracervical block in, 3637 nitrous oxide in, 70 perineal surgery in
psychoprophylaxis in, 3031 opiates in, 71 radical vulvectomy in, 136137
pudendal nerve block in, 3738 opioids in, neuraxial, 65, 66f stress incontinence in, 136137
systemic, 31, 31t pre-eclampsia and, 8384 postoperative considerations in, 137138
Analgesia, postcesarean, 7374 premedication in, 5961, 61b preoperative procedures and
fentanyl in, 74, 75t preoperative assessment and, 58, 58f anxiety and, 132
meperidine in, 74, 75t preoperative preparation in, 5962, 61b general considerations in, 132133
multimodal therapy in, 77, 77f propofol in, 70 nausea/vomiting prevention in, 133,
nonopioid therapies in, 76, 76t rapid sequence induction in, 6769 133b
opioids in regional anesthesia in, 6267, 63f, pre-emptive analgesia in, 133
intramuscular/subcutaneous, 7576 64t, 66f transvaginal surgery in
neuraxial, 7475, 74t, 75t complications in, 6667 dilation/curettage in, 136
oral, 76, 76t rocuronium in, 71 dilation/evacuation in, 136
pain therapies/outcome in, 77, 77f Sellicks maneuver in, 67, 69 laser therapy in, 136
PCA in, 75, 75t, 77 sensory blocks in, 63, 65 Anesthesia, general
PECA in, 7475, 74t, 7778 spinal anesthesia in, 6364, 64t in cesarean delivery, 6770, 68f
159
160 INDEX
Endometriosis, pelvic pain management Fetal outcome risk, in anesthesia/nonobstetric High-risk obstetric patients (Continued)
and, 141142 surgery, 20, 20b, 22 morbid obesity in, 100104, 100b
Endoscopy, in anesthesia/fetal surgery, Fetal pulse oximetry (FPO), in fetal (Continued)
2728, 27t monitoring/resuscitation, 49 CSE and, 102, 103
Endotracheal intubation. See also Failed Fetoscopy, in anesthesia/fetal surgery, 25, epidural anesthesia in, 101102, 103
intubation; Intubation 2728, 27t general anesthesia in,102104
maternal physiology and, 5, 5b FHR. See Fetal heart rate induction agents and, 104
Endotracheal tubes (ETT), in fetal Fluid preload, in cesarean delivery, 6162 labor analgesia for, 101102
monitoring/resuscitation, 52, 53, 53t, 54 FPO. See Fetal pulse oximetry obstetric concerns in, 100101
Epidural anesthesia Functional residual capacity (FRC), in physiologic changes in, 100, 100b
in cesarean delivery, 6465 maternal physiology, 3, 4f multiple gestation in, 9496, 94b
for labor/delivery, 3136, 32f, 33t, 34t anesthetic management of, 9596
Epidural infusions, for labor/delivery, 33t complications of, 9495, 94b
Epinephrine G obstetric management of, 95
in fetal monitoring/resuscitation, 53, 54 obstetric hemorrhage in, 8491, 85b, 87f,
for labor/delivery, 36 Gastrointestinal changes, 88f, 89f
maternal pharmacology and, 11 anesthesia/nonobstetric surgery and, abruptio placenta in, 8586, 85b
Ergot alkaloids, maternal pharmacology 1920, 20b anesthetic management of, 86, 8788,
and, 16, 16b Gastrointestinal physiology, in maternal 8889
Estrogens, in gynecologic patient physiology, 56, 6b classification of, 85
pharmacology/physiology issues, General anesthesia. See Anesthesia, placenta accreta in, 8889, 88f
126128, 127b general placenta previa in, 8688, 87f
Etiology, of pelvic pain management, 140 Guidelines for Regional Anesthesia uterine rupture in, 8991, 89f
Etomidate, in cesarean delivery, 70 Obstetrics, 148149 VBAC in, 9091
ETT. See Endotracheal tubes obstetric anesthesiology services and, pre-eclampsia in, 7984, 80b, 81t
Ex utero intrapartum therapy (EXIT), 114, 115b anesthetic management of, 8184
anesthesia/fetal surgery and, 25, 26t, 28 Gynecologic malignancies cesarean anesthesia in, 8384
External cephalic version, in high-risk gynecologic patient drug interactions in, 84
obstetric patients, 9394 pharmacology/physiology issues and, labor analgesia in, 8283
129130, 130b magnesium sulfate and, 8081, 81t, 84
gynecologic/oncologic procedures obstetric management of, 8081, 81t
F and, 134 risk factors in, 7980, 80b
spinal anesthesia in, 84
Failed intubation, in cesarean delivery, 69 risk factors in, 147
Fentanyl H Hypotension
in analgesia/postcesarean, 74, 75t anesthesia/nonobstetric surgery and, 23
for labor/delivery, 33, 33t, 34t, 35b Headache, in complications/risk in complications/risk management,
maternal pharmacology and, 12t, 13 management, 123 120121
Fetal defects, anesthesia/fetal surgery and, Head/ears/eyes/nose/throat, in maternal Hysterectomy, in gynecologic/oncologic
25, 26t, 27t physiology, 5, 5b, 5t procedures, 137
Fetal heart rate (FHR), in fetal Hematologic physiology, in maternal
monitoring/resuscitation, 4041, 40f, physiology, 67, 7f
4248, 43f, 44f47f, 55b High spinal anesthesia, in cesarean I
Fetal monitoring/resuscitation delivery, 66
antepartum fetal assessment in, 4042, High-risk obstetric patients Illness rates, gynecologic patient
40f, 41t, 42t abnormal presentation in, 9194, 92f pharmacology/physiology issues and, 129
Apgar score in, 5051, 50t breech vaginal delivery in, 9293 Induction agents
BPP in, 4142, 42t external cephalic version in, 9394 in cesarean delivery, 70
bradycardia in, 39, 40, 41, 46, 47f, 50, 53 cardiac disease in, 104112, 106f morbid obesity and, 104
chest compressions in, 53, 53t, 54 anesthetic management and, 111112 Informed consent, complications/risk
CST in, 41, 41t aortic insufficiency in, 108109 management and, 121122, 124, 124b
epinephrine in, 53, 54 aortic stenosis in, 107108 Inhalation agents, maternal pharmacology
ETT in, 52, 53, 53t, 54 congenital heart disease and, 104105 and, 14
fetal ECG in, 4950 Eisenmengers syndrome and, 105107, Insulin, maternal physiology and, 7, 7f
fetal scalp sampling in, 48, 48t 106f Intrapartum fetal assessment, in fetal
fetal stress reactions and, 3940 left-to-right shunts and, 105 monitoring/resuscitation, 4250, 43f,
FHR in, 4041, 40f, 4248, 43f, 44f47f, 55b medical/obstetric management and, 111 44f47f, 48t
FPO in, 49 mitral insufficiency in, 110111 Intrathecal technique, for labor/delivery,
intrapartum fetal assessment in, 4250, mitral stenosis in, 109110 34, 34t
43f, 44f47f, 48t peripartum cardiomyopathy in, Intubation, anesthesia/nonobstetric
medication administration routes in, 54 111112, 111b surgery and, 20
medications in, 5354 phenylephrine and, 105
neonatal resuscitation and, 5152 tetralogy of Fallot and, 105
newborn care and, 5255, 53t, 55b valvular, 107111 J
NST in, 4041 diabetes mellitus in, 96100, 96t, 98b
respiratory/circulatory changes and, anesthetic management of, 98100, 99f JCAHO (Joint Commission on Accreditation of
5152 DKA in, 97, 98 Health Care Organization), in obstetric
resuscitative equipment in, 5253 obstetric management of, 9798, 98b anesthesiology services, 115
STAN method in, 4950 Whites classification of, 96, 96t
tachycardia in, 39, 40, 41, 44 morbid obesity in, 100104, 100b
ultrasound in, 50 anesthetic management for, 101 K
umbilical cord pH in, 4849 cesarean delivery anesthesia in,
withholding resuscitation in, 54 102105 Ketamine, in cesarean delivery, 70
162 INDEX
Vaginal birth after cesarean (VBAC) (Continued) Valvular cardiac disease, in high-risk obstetric W
obstetric anesthesiology services and, patients, 107111
115, 116, 116b Vasopressors, maternal pharmacology and, West Haven-Yale Multidimensional Pain
Vaginal delivery, complications/risk 1516, 16b Inventory (WHYMPI), pelvic pain
management and, 118119, 119b VBAC. See Vaginal birth after cesarean management and, 140
Vagolytic drugs, maternal pharmacology Vecuronium/atracurium, in Whites classification, of diabetes mellitus in,
and, 16 anesthesia/cesarean delivery, 71 96, 96t